Professional Documents
Culture Documents
*Blood pressure values are for 50th percentile pressure at 50th percentile height for age. Males listed first, females listed second.
Normal Arterial Blood Gas Values When Breathing Room Air (at 37°C)
Age pH PaCO2 (mm Hg) PaO2 (mm Hg) HCO3 (mEq/L)
Premature infant ≥ 7.25 45–55 45–65 20–24
(<28 weeks’ gestation)
Newborn (birth) 7.26–7.29 55 60 19
Newborn (>24 hours) 7.37 33 70 20
Infant (1–24 months) 7.40 34 90 20
Child (7–19 years) 7.39 37 96 22
Adult (>19 years) 7.35–7.45 35–45 90–110 22–26
2831_FM_i-xx 13/03/14 3:45 PM Page i
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
To Samuel,
Preface
I
knew from the moment I started my respiratory training at the Indi-
ana University of Pennsylvania School of Respiratory Care that
I wanted to focus on childhood cardiopulmonary management.
I actively sought out extra clinical rotations in neonatal and pediatric
units and spent all of my low-acuity clinical time interrogating neonatal
and pediatric RTs about the clinical units, the equipment, and the role
of the RT in interdisciplinary patient management. I was thrilled to se-
cure a position upon graduation at the Johns Hopkins Neonatal Intensive
Care Unit because it was one of the few places I knew that would hire a
new RT into a pediatric specialty area.
My story is not a unique one. It is challenging for RT students who
may want to specialize in caring for children, because neonatal and pe-
diatric clinical rotations are inconsistent. Some students may not see a
large portion of the patients, disease processes, or therapeutic modalities
discussed in class, which means they graduate without first-hand experi-
ence. Nationally, the neonatal and pediatric exposure is different for grad-
uates from different programs, and even classmates may have very
different clinical experiences. In this text I hope to assist in giving students
a cognitive understanding of pediatric and neonatal diseases, as well
as a foundation of patient experiences that will help build a thorough un-
derstanding of how to translate that knowledge to the bedside. The clin-
ical cases woven throughout this text provide readers with a context to
understand the clinical information presented, as well as an opportunity
to develop critical-thinking skills.
Consistent Format
Each disease chapter is presented in the same way and in the same order,
including sections discussing background, pathophysiology, clinical man-
ifestations, management and treatment, and course and prognosis.
Background information in each chapter seeks to answer questions
such as: What is the frequency of the condition (how common is it)?
What patient population does it most commonly affect (e.g., neonates,
young children, males versus females)? Is it congenital? Is it an infec-
tious disease? General causes and related descriptions are included.
vii
2831_FM_i-xx 13/03/14 3:45 PM Page viii
viii ■ Preface
Pathophysiology focuses on what happens physio- • Special Populations: This feature identifies key
logically in the body, how the disease progresses, and patient demographics that may require you
variants or different types of the disease. Clinical as the therapist to employ special care or con-
manifestations reveal clinical signs and symptoms siderations when caring for a patient with this
such as vital signs, radiography, blood gas, and other disease.
physical findings, as well as other diagnostic tools.
Management and treatment include surgical inter- Icons
ventions, pharmacological therapies, respiratory and
ventilatory interventions, and other multidiscipli- Icons can be found throughout each chapter to help
nary strategies. The course and prognosis section identify key information:
discusses morbidity and mortality rates, long-term
complications, life span, projected course and hos- Therapist Alert
pital stay, as well as public burden and health-care
costs. Pharmacology
At the end of each chapter, additional case studies
for other diseases discussed within the chapter ap- ABG
pear, incorporating critical-thinking questions. There
are also multiple-choice questions that focus on the
major learning objectives of the chapter. Mechanical Ventilation
Contributors
JANE B ENSON, MD E LLEN D EUTSCH , MD, FACS,
Assistant Professor FAAP
Pediatric Radiology Director, Simulation and Systems
The Johns Hopkins School Integration
of Medicine Center for Simulation, Advanced
Baltimore, MD Education, and Innovation
The Children’s Hospital
R ENEE B OSS, MD, MHS
of Philadelphia
Assistant Professor, Division of
Philadelphia, PA
Neonatology, Department
of Pediatrics D HEERAJ G OSWAMI , MD
The Johns Hopkins School Pediatric Critical Care Fellow
of Medicine The Johns Hopkins Hospital
The Johns Hopkins Berman Institute Baltimore, MD
of Bioethics
ROBERTA H ALES, MHA,
Baltimore, MD
RRT-NPS, RN
M ARISSA B RUNETTI , MD Simulation Educator
Attending Intensivist Center for Simulation, Advanced
The Children’s Hospital Education and Innovation
of Philadelphia The Children’s Hospital
Philadelphia, PA of Philadelphia
Philadelphia, PA
H EATHER C HANDLER , MD,
MPH A NDREA L. H ONESTO,
Assistant Professor, Pediatric BS, RRT
Critical Care Respiratory Care Practitioner II
Emory University Cystic Fibrosis Center
Atlanta, GA The Johns Hopkins Hospital
Baltimore, MD
SHAWN COLBOURN, AS, RRT-NPS
Pediatric Respiratory Therapist E LIZABETH A. H UNT, MD,
The Children’s Hospital MPH, PHD
of Philadelphia Associate Professor of Anesthesiology
Philadelphia, PA and Critical Care Medicine
Associate Professor of Pediatrics
E LIZABETH C RISTOFALO, MD
The Johns Hopkins School
Assistant Professor of Pediatrics
of Medicine
The Johns Hopkins School
Baltimore, MD
of Medicine
Baltimore, MD
ix
2831_FM_i-xx 13/03/14 3:45 PM Page x
x ■ Contributors
Reviewers
T ERI A LLEN, BSHA, RRT-NPS ROBERT L. J OYNER , J R ., PHD,
Neonatal/Pediatric Clinical Education RRT, FAARC
Coordinator Associate Dean, Henson School of
University of California–Irvine Science & Technology
Orange, CA Director, Respiratory Therapy
Program
N ICKI S UE B LY, BS, RRT-NPS
Salisbury University
Director of Clinical Education,
Salisbury, MD
Respiratory Care
Highline Community College C HRISTY J. K ANE , PHD,
Des Moines, WA RRT-NPS
Department Chair, Respiratory
L ISA C ONRY, MA, RRT
Therapy Department
Director of Clinical Education
Bellarmine University
Spartanburg Community College
Louisville, KY
Spartanburg, SC
A LETA K AY M ARTIN, BSRC,
H ELEN S. C ORNING, RRT
RRT-NPS
Registered Respiratory Therapist
Clinical Educator
Shands/UF Medical Center
Children’s Medical Center
Jacksonville, FL
Dallas, TX
J UANITA DAVIS, RRT
K ERRY J. M C N IVEN, MS, RRT
Faculty
Professor, Director
Southern Alberta Institute of
Manchester Community College
Technology
Manchester, CT
Alberta, Canada
L ISA J. P IERCE , MSA, BS, RRT
M ARTHA D E S ILVA , MED, RRT-
Clinical Director, Respiratory Care
AC-E
Augusta Technical College
Program Director, Respiratory Care
Augusta, GA
Massasoit Community College
Brockton, MA G EORGETTE ROSENFELD, PHD,
RRT, RN
L EZLI H EYLAND, BS, RRT-NPS
Department Chair, Respiratory Care
Program Director, Respiratory Care
Indian River State College
Program
Fort Pierce, FL
Oklahoma City Community College
Oklahoma City, OK M ELISSA D. S MITH , BS, RRT
Respiratory Care Education
N ANCY A. J OHNSON, RRT-NPS
Coordinator
Pediatric Respiratory Education
Chapter 8 President, Louisiana
Coordinator
Society for Respiratory Care
University Hospitals of Cleveland
St. Tammany Parish Hospital
Rainbow Babies
Covington, LA
Children’s Hospital
Cleveland, OH
xi
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xii ■ Reviewers
Acknowledgments
I
owe a great debt to many people who have made this book possible.
First, I would like to thank all my contributing authors, whose
expertise in neonatal and pediatric medicine was invaluable to the
success of this text. Special thanks to Patricia Nolan for creating the test
bank, Laura Shipp for creating the instructor presentations, and Dennise
Stickley for compiling the glossary.
Thank you to Andy McPhee and Quincy McDonald from F. A. Davis
for reaching out to me with the crazy idea to build a new and innovative
pediatric respiratory care textbook. It was their leap of faith that started
me on this path. A first-edition textbook takes a tremendous amount of
editorial work and support. I’d like to thank Mackenzie Lawrence for
her patience and guidance during the early stages of development and
Joanna Cain and Pamela Speh of Auctorial Pursuits, Inc. for their direc-
tion during the completion of the manuscript.
I owe so much to my family for their patience, encouragement, and
perseverance through this project. I give tremendous thanks to my par-
ents and my mother-in-law, who helped provide a quiet home for research
and development. When I started this project, I was a mother of one pre-
schooler; now I have a second child. I am grateful for the special role that
motherhood provides. Most importantly, I have tremendous gratitude
for my husband, Jordan, who encouraged me to start this project and
motivated me along the way until its completion. He also spent many
single-dad weekends with the kids so Mommy could write her book.
xiii
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2831_FM_i-xx 13/03/14 3:45 PM Page xv
Contents
Chapter 1
Making Sense of Caring for Kids: A Different
Approach to Respiratory Care
Julianne S. Perretta, MSEd, RRT-NPS, CHSE 1
Anatomical and Physiological Differences Between Children
and Adults 3
Patient Assessment 6
Pharmacology 14
Equipment Selection 16
Intensive Care Unit Classifications 17
Evidence-Based Medicine 18
Section One
Fetal Development and Transition to Extrauterine Life
Chapter 2
Fetal Cardiopulmonary Development
Julianne S. Perretta, MSEd, RRT-NPS, CHSE 31
Determining Gestational Age 33
Fetal Lung Development 33
Fetal Cardiac Development 35
Fetal Neurological Development 36
Fetal Circulation 37
Changes to Fetal Circulation at Delivery 38
Assessing Fetal Lung Maturity 39
Tocolytics and Glucocorticoids During Preterm Labor 41
Implications of Development on Neonatal Course 41
Chapter 3
Resuscitation of the Newborn During Transition
to Extrauterine Life
Theodora A. Stavroudis, MD 45
The Three Stages of Labor 46
Fetal Monitoring During Labor and Delivery 47
Transition to the Extrauterine World 47
Section Two
Perinatal Lung Diseases and Complications
Chapter 4
Respiratory Distress Syndrome
Julianne S. Perretta MSEd, RRT-NPS, CHSE 65
Hyaline Membrane Disease/Respiratory Distress Syndrome 67
xv
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xvi ■ Contents
Chapter 5
Apnea of Prematurity and Bronchopulmonary
Dysplasia
Julianne S. Perretta, MSEd, RRT-NPS, CHSE 111
Apnea of Prematurity 112
Bronchopulmonary Dysplasia 118
Chapter 6
Disease of Full-Term Infants
Sara Jann Mola, MD • Webra Price-Douglas, PhD, CRNP, IBCLC • Julianne S.
Perretta, MSEd, RRT-NPS, CHSE • Shannon Poling, BS, RRT
Gary Oldenburg, RRT-NPS 135
Persistent Pulmonary Hypertension of the Newborn 136
Meconium Aspiration Syndrome 151
Transient Tachypnea of the Newborn 157
Section Three
Common Neonatal Complications
Chapter 7
Pulmonary Complications
Julianne S. Perretta, MSEd, RRT-NPS, CHSE 165
Atelectasis 166
Pulmonary Interstitial Emphysema 170
Pneumothorax 174
Pneumomediastinum 176
Pneumopericardium 177
Pneumonia 178
Chapter 8
Multisystem Complications
Elizabeth Cristofalo, MD • Julianne S. Perretta, MSEd, RRT-NPS, CHSE
Matthew Trojanowski, BA, RRT 185
Intraventricular Hemorrhage 187
Patent Ductus Arteriosus 193
Necrotizing Enterocolitis 199
Retinopathy of Prematurity 204
Section Four
Congenital Anomalies
Chapter 9
Abdominal Defects
Julianne S. Perretta, MSEd, RRT-NPS, CHSE 213
Congenital Diaphragmatic Hernia 214
Gastroschisis 226
Omphalocele 228
2831_FM_i-xx 13/03/14 3:45 PM Page xvii
■ Contents xvii
Chapter 10
Airway Abnormalities
Ellen Deutch, MD FACS, FAAP • Safeena Kherani, MD FRCSC 237
Airway Abnormalities of the Nasal Passages and Nasopharynx 239
Choanal Atresia 239
Other Conditions Affecting the Nasal Passages and
Nasopharynx 241
Airway Abnormalities of the Oral Cavity and Oropharynx 242
Robin Sequence 242
Other Conditions Affecting the Oral Cavity and Oropharynx 244
Airway Abnormalities of the Supraglottis 244
Laryngomalacia 245
Other Conditions Affecting the Supraglottis 246
Airway Abnormalities of the Glottis 247
Recurrent Respiratory Papillomatosis 247
Other Conditions Affecting the Glottis 248
Airway Abnormalities of the Subglottis 249
Subglottic Stenosis 249
Other Conditions Affecting the Subglottis 251
Airway Abnormalities of the Trachea and Bronchi 251
Tracheoesophageal Fistula 251
Other Conditions Affecting the Trachea and Bronchi 253
Tracheotomies 253
Chapter 11
Acyanotic Heart Defects
Stacey Peddy, MD • Heather Chandler, MD, MPH 261
Atrial Septal Defect 263
Ventricular Septal Defect 266
Atrioventricular Septal Defect 267
Aortic Stenosis 268
Pulmonic Stenosis 270
Coarctation of the Aorta 271
Double Aortic Arch 273
Chapter 12
Cyanotic Heart Defects
Marissa Brunetti, MD • Jamie McElrath Schwartz, MD 279
Tetralogy of Fallot 282
Total Anomalous Pulmonary Venous Return 285
Transposition of the Great Arteries 288
Hypoplastic Left Heart Syndrome 291
Ebstein Anomaly 296
Truncus Arteriosus 298
Section Five
Pediatric Diseases With Respiratory Implications
Chapter 13
Asthma
Julianne S. Perretta, MSEd, RRT-NPS, CHSE 307
Asthma 308
Chapter 14
Cystic Fibrosis
Peter Mogayzel, Jr. MD, PhD, • Holly Loosen, PT
Karen Von Berg, PT, • Andrea L Honesto, BA, RRT 355
Cystic Fibrosis 356
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xviii ■ Contents
Chapter 15
Pediatric Pulmonary Diseases
Vinay Nadkarni, MD • Roberta Hales MHA, RRT-NPS, RN
Shawn Colbourn, AS, RRT-NPS 381
Bronchiolitis 382
Pneumonia 393
Acute Respiratory Distress Syndrome 399
Chapter 16
Pediatric Infectious Airway Diseases
Stacey Mann, BS, RRT 415
Epiglottitis 417
Croup 422
Bacterial Tracheitis 426
Chapter 17
Neuromuscular Disorders
Sharon McGrath-Morrow, MD, MBA • Suzanne Prestwich, MD 433
Guillain- Barré Syndrome 438
Myasthenia Gravis 441
Tetanus 442
Botulism 443
Muscular Dystrophy 445
Spinal Muscular Atrophies 447
Chapter 18
Pediatric Accidents With Pulmonary Involvement
Elizabeth A. Hunt, MD, MPH, PhD • Dheeraj Goswami, MD 453
Near-Drowning 454
Inhalation Injuries 462
Upper-Airway Injury 462
Direct Lung Injury 463
Systemic Complications 465
Cyanide Poisoning 466
Aspiration 467
Foreign Body Aspiration 468
Chemical Pneumonitis 470
Hydrocarbons 470
Lipoids 471
Secretions 472
Gastric Secretions 474
Chapter 19
Pediatric Neurological Accidents
Jennifer Schuette, MD 481
Traumatic Brain Injury 482
Spinal Cord Injury 492
Neurogenic Pulmonary Edema 495
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■ Contents xix
Section Six
Ethics and Pediatric Palliative Care
Chapter 20
Ethics in Perinatal and Pediatric Respiratory Care
Renee Boss, MD, MHS • Megan McCabe, MD, FAAP 503
Principles of Bioethics 504
Professional Ethics 506
Clinical Ethics 509
Clinical Scenarios With Ethical Implications for Pediatric
Respiratory Care 514
Chapter 21
Palliative and End-of-Life Care
Wynne Morrison, MD, MBE 525
Framing the Discussion About Appropriate Goals of Care 528
Early Referral/Concurrent Care 530
Do Not Attempt Resuscitation Orders 531
Discontinuing Mechanical Ventilation 533
Treating Dyspnea 535
Location of Death 538
Supporting the Family 539
Supporting the Team 539
Glossary 545
Index 563
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2831_Ch01_001-030 13/03/14 3:05 PM Page 1
Chapter 1
Making Sense of
Caring for Kids:
A Different Approach
to Respiratory Care
Chapter Outline Key Terms
Chapter Objectives Adverse drug event
Key Terms Applicability
Jamie Thibeaux Capillary blood gas (CBG)
Anatomical and Physiological Cricoid pressure
Differences Between Children Evidence-based medicine
and Adults Exclusivity
Patient Assessment Expressive language
Developmental Milestones Functional residual capacity (FRC)
Pain Assessment Medication error
Weight Off-label use
Vital Signs Pharmacodynamic
Pulse Oximetry Pharmacokinetic
Blood Gas Monitoring Pores of Kohn
Pharmacology Proliferating
Medication Errors Receptive language
Aerosolized Medications Sniffing position
Equipment Selection Target effect
Intensive Care Unit Classifications Transcutaneous monitoring
Evidence-Based Medicine Validity
Critical Thinking Questions:
Jamie Thibeaux
Multiple-Choice Questions
References
1
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2 Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care
Chapter Objectives
After reading this chapter, you will be able to:
1. Discuss two reasons why all respiratory therapists should be able to care for pediatric patients.
2. Identify key differences in the anatomy of children compared to adults and the implications of those
differences on the respiratory management of pediatric patients.
3. Describe how differences in neonatal and pediatric physiology affect work of breathing.
4. Identify three ways that pediatric patient assessment must be adjusted based on developmental milestones.
5. List normal and critical values for heart rate, respiratory rate, blood pressure, and arterial blood gas at
different ages.
6. Discuss the ways to monitor oxygenation and ventilation in children.
7. List three ways to minimize the risk of medication errors in pediatric patients.
8. Describe how using target effect can drive the dosing of pediatric aerosol medications.
9. Choose a delivery method for a certain age when giving an aerosolized medication.
10. Select respiratory care equipment for a pediatric patient based on age or weight.
11. Differentiate among the three levels of neonatal intensive care units and between the two levels of
pediatric intensive care units as proposed by the American Academy of Pediatrics.
12. Define evidence-based medicine and describe its implications on pediatric health care.
I
n its 2010 annual survey, the American Hospital For example, children express themselves differently
Association listed the number of registered hos- than adults, and communication evolves as children
pitals in the United States at 5,754 (1). Of this grow. Children come in different sizes, and equipment
total, fewer than 5% were pediatric hospitals. For must be chosen accordingly. Expected normal vital
clinicians who work in the hospital setting, this signs are different based on age, and pediatric patient
means that the vast majority of jobs are caring for assessment, particularly the assessment of pain, may
adult patients, not children. Why then is it important need to be modified based on age. Pharmacological
for respiratory therapists to know how to care for dosing and responses are different for adults and chil-
pediatric patients? First, most community hospitals dren, and different delivery methods may need to be
have at least a pediatric in-patient unit. Second, pe- employed.
diatric long-term and respiratory care makes up a This chapter discusses these differences and how
significant portion of home care services. they affect how respiratory care is provided to chil-
Many clinicians believe that the sickest patients dren. The health-care services needed for children are
are the most challenging to care for. However, it extensive and are frequently available only in neona-
could be argued that stable patients who could dete- tal and pediatric inpatient settings and intensive care
riorate quickly and become critically ill are more units. This chapter identifies current classification
2831_Ch01_001-030 13/03/14 3:05 PM Page 3
Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care 3
systems for neonatal and pediatric intensive care • In children, the size of the tongue compared
units recommended by the American Academy of to the oral cavity is much larger, particularly in
Pediatrics (AAP). It also describes evidence-based infancy. This makes the tongue a natural air-
medicine and its importance in current patient way obstructer. An oral airway should be a first
management. As research on children advances, it is line of defense when beginning bag-mask venti-
the health-care community’s responsibility to keep lation on an unconscious child to avoid tissue
current on new recommendations and upcoming airway obstruction.
changes to practice. • Children have large tonsils and adenoids
and a large amount of lymphoid tissue in
Anatomical and Physiological the pharynx. These are potential areas for
swelling, which can cause upper airway ob-
Differences Between Children struction. They may also bleed significantly
and Adults during trauma or intubation, obstructing
views and risking aspiration.
Before identifying anatomical and physiological • An infant’s epiglottis is larger, less flexible,
differences between different ages, it is important to and omega or U-shaped. It lies more horizon-
first identify the age ranges used to describe pediatric tally than an adult’s and is more susceptible
patients. These terms are found in Box 1-1, and they to trauma.
will be used throughout the textbook to define time • The angle between the epiglottis and laryngeal
periods in childhood. opening is more acute in an infant than in
Many of the anatomical differences seen between an adult, which makes blind nasal intubation
children and adults are most pronounced in infancy. difficult.
This is seen clearly when studying the nasopharynx, • In infancy, the glottis begins at the first cervical
oropharynx, and pharynx, for example, because they vertebrae (C1). As the thorax and trachea
continuously evolve throughout childhood. These grow, the glottis moves to C3 to C4 by age 7
changes have implications for airway management. and is located at C5 to C6 in adulthood. This
See Table 1-1 for a summary of anatomical differ- makes the glottis in children higher and more
ences and their implications. anterior than in adults.
Beginning in the nasopharynx, differences include • The cricoid ring is the smallest portion of a
the following: child’s airway, whereas in adults the vocal
• Infants are considered obligate nose breathers. cords are the smallest portion of the airway.
They are not totally dependent on nose breath- An uncuffed endotracheal tube (ETT) pro-
ing but breathe through their noses preferen- vides an adequate seal in a small child be-
tially. Any obstruction, such as mucus or cause it fits snugly at the level of the cricoid
inflammation, can increase resistance to airflow ring. When using an uncuffed ETT, correct
and work of breathing (WOB). tube size is imperative because air can leak
around an ETT that is too small, and tracheal
damage can result from an ETT that is too
large.
Box 1-1 Childhood Age Ranges
• Children have small cricothyroid membranes,
Very/extremely Less than 32 weeks and, in children younger than 3 years, it is
preterm neonate gestational age virtually nonexistent. This means emergency
Moderate preterm 32 to 36 weeks gesta- surgical airway techniques such as needle
neonate tional age cricothyrotomy and surgical cricothyrotomy
Late preterm neonate 34 0/7 to 36 6/7 weeks are extremely difficult, if not impossible, in
gestational age infants and small children.
Full-term neonate 38 to 42 weeks gesta- • A child’s trachea is smaller and more malleable
tional age, to first than an adult’s trachea, meaning it is more sus-
month of postnatal ceptible to changes in shape when under pres-
life sure. The newborn trachea is approximately
Infant 1 to 12 months 6 mm in diameter, and the cartilage is not fully
Toddler 12 to 36 months developed, making it more compliant than
Preschool-age child 4 to 51/2 years the adult trachea. This means the trachea of a
School-age child 51/2 to 12 years newborn collapses more easily, and in the pres-
Adolescent 12 to 18 years ence of inflammation, airway resistance will
Adult Greater than 18 years increase exponentially. Increased inspiratory
pressure during respiratory distress causes
2831_Ch01_001-030 13/03/14 3:05 PM Page 4
4 Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care
Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care 5
increased negative intrathoracic pressure and However, the occiput (back part of the skull) is larger
can lead to collapse of the extrathoracic tra- in children and may cause flexion of the neck and
chea. Caution should be taken when caring inadvertent obstruction of the airway. To align the
for pediatric patients with increased WOB be- airway in an adult, a roll can be placed under the
cause increased respiratory effort by patients head. In children this is not needed, and infants
to alleviate airway obstruction may instead may need a shoulder roll to achieve sniffing position.
exacerbate it. See Figure 1-2 for an example of the proper sniffing
• The diameter of children’s airways is smaller position for an infant, child, and adult.
than the airways of adults, making children In summary, infants and toddlers (younger than
more susceptible to airway obstruction caused 2 years) have higher anterior airways. Children older
by swelling. than 8 years have airways similar to adults. The age
• The shorter trachea of children makes tube range of 2 to 8 years old marks a transition period,
misplacement and accidental extubation much when the above-mentioned anatomical differences
more frequent than in adults. Small tube mi- may have varying effects on airway management.
grations due to head movement can cause On the positive side, the anatomical differences are
ETT dislodgement (Fig. 1-1). consistent from one child to another, so they can be
anticipated when managing a child’s airway. This is
With both adults and children, an effective way of
not true in adults, however, in whom complex airway
opening the airway is to place the patient in the sniff-
issues are related to body build, arthritis, and chronic
ing position, in which the patient’s head and chin are
disease.
thrust slightly forward to keep the airway open.
Moving into the thoracic cavity, additional differ-
ences must be addressed.
• An infant’s ribs and sternum are mostly carti-
lage, and the ribs lay more horizontally than do
those of an adult. The thoracic cage thus offers
little stability, and the chest wall will collapse
with negative pressures. This makes retractions
more pronounced in infants and most obvious
in preterm infants. The cartilaginous ribs do,
however, mean that closed-chest compressions
from cardiopulmonary resuscitation do not
usually cause rib fractures in children (2).
• Breathing for infants is mostly diaphragmatic,
making them abdominal or “belly breathers.”
Instability of the thoracic cage makes it diffi-
cult to increase minute ventilation by increas-
ing thoracic volume. Infants must drop the
diaphragm more to increase tidal volume,
which increases WOB. To avoid increased
WOB, infants usually increase respiratory
rate to increase minute ventilation.
• The angle of the right mainstem at the carina
is lower in children than adults, making them
more susceptible to right mainstem intubation
and foreign body obstruction of the right lung.
• At birth, the number of conducting airways is
completely developed. However, airway diame-
ter increases with lung growth. This explains
the phenomenon of children “outgrowing” re-
active airways disease. It is less likely that the
swelling and smooth muscles are no longer re-
active; rather, the degree of airway obstruction
is less pronounced as a result of the increased
airway diameter.
• There is no effective way to measure number
Figure 1-1 How Head Rotation Affects Endotracheal of alveoli in live humans. A recent electron
Tube Position Within the Trachea microscopy study calculated that the adult
2831_Ch01_001-030 13/03/14 3:05 PM Page 6
6 Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care
male lung has approximately 480 million to diaphragm. This can also make gastric insuffla-
500 million alveoli, with 1 cubic millimeter tion during bag-mask ventilation more haz-
of lung parenchyma having approximately ardous for children. Using cricoid pressure, also
170 alveoli (3). Between birth and adulthood, known as the Sellick maneuver (pushing the
there is a 20-fold multiplication of alveolar cricoid cartilage against the cervical spine, com-
surface area (4). There is no current consensus pressing the esophagus to prevent passive regur-
in the scientific community to say how or when gitation), has been shown to decrease gastric
the multiplication occurs. A 2006 article identi- insufflation in children, even when peak inspira-
fies different studies that list the age at which tory pressures greater than 40 cm H2O are used
the alveoli stop proliferating (growing) as 2, 8, (5). It can also decrease the risk of aspiration.
11, and 20 years (4). To generalize on these This is especially important for infants, in
studies, when body growth stops, so does lung whom gastric distention can significantly com-
growth, with a large portion of lung prolifera- promise ventilation.
tion occurring in the first 3 years of life.
Furthermore, the basal oxygen consumption of
• The alveolar sacs in a newborn are structurally
children is twice that of adults: 6 mL O2/kg for chil-
different from those of an adult. For the first
dren versus 3 mL O2/kg for adults. The clinical im-
several years of life, the lungs undergo a phase
plication of lower pulmonary reserve and increased
known as microvascular maturation, in which
oxygen consumption is that children will desaturate
the septum between alveoli fuse and thin out,
more rapidly than will adults. Recommendations for
and after 2 to 3 years look like a smaller ver-
airway management suggest that clinicians should
sion of the adult lung. The alveoli in newborns
be prepared to provide bag-mask ventilation with
also do not have Pores of Kohn (minute open-
1.0 FIO2 if a child’s oxygen saturation falls below
ings thought to exist between adjacent alveoli),
90% (5).
which decreases a newborn’s capacity for col-
lateral circulation of air. The lack of collateral Patient Assessment
air circulation means that during lower airway
obstruction, newborns and infants will be af- Patient assessment requires the gathering of both
fected more significantly and decompensate subjective and objective information about past and
more rapidly. current health. Gathering subjective information
about children can be challenging, and objective in-
Compared to adults, infants and children have
formation such as vital signs and blood gas values
a lower pulmonary reserve, or functional residual
can differ based on age. Respiratory therapists need
capacity (FRC), which is the amount of air remain-
to be aware of these differences to accurately assess
ing in the lungs after a normal resting expiration.
pediatric patients and make clinical decisions based
This is caused by several factors.
on good evidence.
• Infants and children have larger hearts in pro- Obtaining a patient history and chief complaint is
portion to the thoracic diameter, which im- imperative in patient assessment. Differences in the
poses on the lungs and decreases lung capacity. abilities of children of varying ages and disease states
• An infant’s chest wall is more compliant than to comprehend what is being said to them (receptive
an adult’s chest. language) and capacities to communicate their current
• The elastic recoil of a child’s lungs is less than thoughts and feelings (expressive language) make
that of an adult. subjective patient assessment challenging. Social and
• Young children have proportionally large ab- language developmental milestones are important to
dominal contents, which push up against the better communicate with and assess pediatric patients.
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Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care 7
The following list describes the typical progression of Autism Spectrum Disorders
social and language developmental milestones from
infancy up to 5 years. These are general guidelines, Autism spectrum disorders (ASDs) are a group of neu-
and typically developing children may reach these rodevelopmental disabilities that affect the way a child
milestones before or after the stated time frames (2). perceives the world and makes communication and
social interaction difficult. These disorders affect 1 in
• At 3 months old, an infant can begin to produce 88 children in the United States (and 1 in 54 boys) and
long, musical vowel sounds known as cooing. can have a serious impact on how children communi-
She will start to reach for familiar people or cate with health-care providers (6). Signs of ASDs typ-
objects and will anticipate feeding. ically are apparent before age 3 and include delays in
• At 6 months old, an infant will make more ad- language and social development, as well as stereo-
vanced noises (e.g., babbles, razz, and ah-goo typical and repetitive behaviors. No two children with
noises) and can recognize when someone is a ASD present with the same symptoms, so interacting
stranger. She has no expression of anticipatory with them can be challenging. Some children on the
fear, so the 6-month-old’s level of anxiety will spectrum are nonverbal, whereas others have difficulty
reflect that of the parent. with the nuances of social language. Though a child
• At 9 months old, an infant will start to say with ASD may understand questions asked of him or
“mama” and “dada” indiscriminately, gesture, her, the child may struggle to give you an appropriate
wave bye-bye, and understand the word “no.” answer, may not make eye contact, and may be sen-
She will begin exploring the environment, fre- sitive to a stranger’s touch. The child may also have
quently placing items in her mouth, so foreign hyper- or hyposensitivity to pain stimulus, which may
body aspiration begins to be of concern. make him or her more or less reactive to diagnostic
• By 15 months old, a toddler can use 4 to 6 words procedures. Parents and other caregivers of a child
and follow one-step commands (e.g., “Go”). with ASD should be able to offer insight for health-care
She can imitate actions, come when called, co- providers on how to best interact with the child. Have
operate with dressing, and use a spoon and cup. parents and caregivers assist you in obtaining subjec-
• At 18 months old, a toddler says 7 to 10 words tive information from the child and performing assess-
and knows five body parts. She can copy some ment and diagnostic procedures, and ask them for
daily tasks such as sweeping or dusting and advice on how to interact effectively with the child.
play in the company of other children. Cooper-
ating during assessments and asking questions
may begin to occur during this age. A child
such as pain and can cooperate during proce-
at this age may be able to verbalize pain with
dures and assessments.
words like “hurt” or “boo-boo.”
• By 2 years old, a toddler has a 50-word voca- Pain Assessment
bulary, uses pronouns such as “I, you, me”
Pain in particular is difficult to assess in young or
(though not always appropriately), and begins
noncommunicative children, and various tools have
using two-word sentences.
been designed to assist caregivers in evaluating and
• Around 3 years old, a toddler knows at least
managing pain in children.
250 words, knows all pronouns, and can re-
peat two digits. She knows her full name, • Infants: The physiological response to acute
age, and gender. She can assess how she feels pain includes increases in blood pressure, heart
physically but may still need visual cues to rate, and respiratory rate. Also seen are oxygen
help localize sensory input such as pain desaturations, crying, diaphoresis, flushing,
(Special Populations 1-1). and pallor. These are unreliable as indicators
• At 4 years old, a child knows colors, can sing for chronic pain because the body no longer
songs or a poem from memory, and asks ques- has a physiological response to pain. Behav-
tions. She can tell “tall tales” and play coopera- ioral responses can be observed by noting the
tively with a group of children. characteristic and duration of the cry, facial ex-
• At 5 years old, a child can print her first name, pressions, visual tracking (following movement
abides by rules, and likes to help out in daily with the eyes), body movements, and response
tasks such as household chores. Children to stimuli. There is a behavioral assessment
around this age can begin to be physically in- tool, known as the Neonatal Infant Pain Scale
volved in their own medical care, such as using (NIPS) (7), which can be used to quantify pain
their own metered dose inhaler. They also have in preterm neonates and full-term neonates
an improved understanding of physical senses up to 6 weeks old. Face, Legs, Activity, Cry,
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8 Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care
Consolability (FLACC) is a pain scale for pre- formula, and Broselow Tape. The Leffler and Theron
verbal patients to evaluate the effectiveness of formulas are used in children from 1 to 10 years of
implemented pain interventions by quantifying age. The UK-based Leffler formula is similar to the
pain behaviors such as facial expression, leg equations used in the American Heart Association
movement, activity, cry, and consolability by (AHA) training program, Pediatric Advanced Life
using a 0 to 10 scoring system (8). Support. The Theron formula was developed in the
• Preschool-age children: In addition to the same hopes of improving accuracy of weight estimations
physiological and behavioral responses in in- for overweight children (11) and works best in pa-
fants, the Wong-Baker FACES pain rating scale tients weighing greater than 40 kg. The formulas are
is a self-assessment tool that children as young
as 3 years old can use to express pain intensity Leffler: Weight (kg) = (age in months/2) + 4
(Fig. 1-3). Theron: Weight (kg) = (exp [(0.175571 × age in
• School-age children and adolescents: In addition years) + 2.197099]
to noting physiological and behavioral re-
sponses, clinicians can also ask patients to de- The Broselow Tape is a long, durable tape meas-
scribe, locate, and characterize pain. Starting at ure used on a child during a medical emergency. It
around age 7 to 8, children can use the standard is designed for children 12 years or younger, with a
pain rating scale, where 0 is no pain and 10 is the maximum weight of roughly 80 pounds. Using a
worst pain ever experienced. color-coded format, it provides specific medical in-
structions to health-care providers based on the
Weight height and then subsequent weight of the child. It
has a tendency to underestimate weight in larger
Weight is one of the most important pieces of pa-
children but has been shown in younger children to
tient data for children, but it is not often available
be more accurate in determining equipment sizes.
during emergencies. Medication dosages are based
Additional weight estimations are continuously
on weight, with length/height and age being second-
being tested, particularly because height, age, and
ary if weight is not known. The Centers for Disease
weight correlations in the United States are not
Control and Prevention and the World Health
transferrable to other countries. (See Evidence in
Organization have created growth charts for infants,
Practice 1-1.)
school-age children, and adolescents. These charts
are used in preventive care to monitor growth and Vital Signs
development and height versus weight discrepancies. It is important to note that vital sign values are dif-
In acute care settings, they can be used to help ferent for children than for adults, and they vary with
estimate weights or heights when age is known. age. Table 1-2 lists the normal values for heart rate
See Figures 1-4 through 1-7 at the end of the chapter (HR), respiratory rate (RR), and blood pressure (BP)
for male and female growth charts (9). based on age. Once blood pressure is obtained, the
Studies have shown that visual estimations of calculation to determine mean arterial blood pres-
patient weights are usually inaccurate and unreliable sure (MAP) is
(10). Several methods have been developed to esti-
mate a child’s weight during emergencies. Three of MAP = 1/3 systolic pressure + 2/3 diastolic
these methods include the Leffler formula, Theron pressure
Figure 1-3 Wong-Baker FACES Pain Rating Scale. (Copyright 1983, Wong-Baker FACES Foundation,
used with permission. www.WongBakerFACES.org. Originally published in Whaley & Wong’s Nursing Care of Infants
and Children. ©Elsevier Inc.)
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Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care 9
● Evidence in Practice 1-1 So, the normal male MAP at 12 years old would
be 1/3 (106) + 2/3 (62) or 35.3 + 41.3, which is
Mid-Arm Circumference (12) 76.6 mm Hg. MAP is often used in the pediatric
Mid-arm circumference has been used for many setting to evaluate blood pressure stability and
years in the assessment of malnutrition in the develop- effectiveness of cardiac inotropic and sympath-
ing world. In primary schools and kindergartens in omimetic therapies.
Hong Kong, the Healthy Children’s Vital Signs and The techniques for respiratory assessment are
USCOM study recruited healthy Chinese children aged the same for children as for adults. Care must be
1 to 11 years and took weight and mid-arm circumfer- taken, however, when assessing respiratory status
ence measurements, along with other measurements. and obtaining vital signs in children, because ac-
Mid-arm circumference was measured with the child’s curate measurement of HR, RR, pulse oximetry,
right arm relaxed in 90 degrees of flexion at the elbow. and BP can all be affected by patient activity and
Landmarks were located to identify the midpoint of the irritability. In premature infants, it may be difficult
arm, and the tape was wrapped around the arm there, to visualize respiratory rate, so a stethoscope is the
taking care to ensure that the tape lay flat against the best way to calculate spontaneous respiratory rate.
arm without pinching the underlying skin. Mid-arm cir- However, as soon as an infant is touched, he or she
cumference had a strong relationship with weight, and will increase respirations, so it will take time and
this relationship grew stronger with age. The formula, patience to obtain an accurate rate. Breath sounds
weight [kg] = (mid-arm circumference [cm] – 10) × 3, may be more difficult to distinguish in very young
was at least as accurate and precise as the Broselow children, and vocal noise transmissions are more
Tape method and outperformed the Leffler formula in common as a result of whining and crying during
school-age children, but was inadequate in preschool auscultation. Crying can also increase WOB in an
children. The conclusion of this study was that this infant up to 32-fold (5), so it is imperative to try
weight-estimation formula based on mid-arm circum- to keep young children in respiratory distress as
ference is reliable for use in school-age children, and calm as possible. Keeping them in a quiet, comfort-
an arm tape could be considered as an alternative to able environment with familiar people will help
the Broselow Tape in this population. alleviate anxiety and minimize additional respira-
tory distress.
Table 1-2 Normal Vital Sign Values by Age (2, 13, 14)
Age (years) Heart Rate Respiratory Rate Blood Pressure (mm Hg)*
(beats per minute) (breaths per minute) Systolic Diastolic
Newborn 95–160 30–60 72 55
Infant 110–180 24–38 90 54
1 85 53
86 40
2 90–150 22–30 88 42
88 45
3 91 46
89 49
4 93 50
91 52
65–135 20–24
5 95 55
93 54
6 96 55
94 56
7 60–130 97 57
96 57
18–24
8 99 57
96 57
Continued
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10 Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care
Table 1-2 Normal Vital Sign Values by Age (2, 13, 14)—cont’d
Age (years) Heart Rate Respiratory Rate Blood Pressure (mm Hg)*
(beats per minute) (breaths per minute) Systolic Diastolic
9 100 60
100 59
10 102 61
102 60
11 104 61
103 61
12 106 62
60–110 16–22
105 62
13 108 62
107 63
14 111 63
109 64
15 113 63
110 65
16 116 65
14–20
111 66
17 118 67
111 66
60–100
18 12-20 120 80
• The 50th percentile pressure at 50th percentile height for age. Males listed first, females listed second.
Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care 11
Clinical Variations 1-1 than adult samples owing to the smaller volume of
blood available. Errors include the following:
A Missing Link in Pulse Oximetry (17) • Heparin dilution: Because of the smaller sample
During the night, a 14-year-old girl hospitalized with size, neonatal and pediatric samples are more
leukemia required the attention of the on-call physician susceptible to liquid heparin dilution errors.
for dyspnea associated with tachycardia. General phys- Heparin has a lower pH than blood, so heparin
ical examination revealed pallor and tachycardia at will lower pH without affecting PaCO2. This
165 bpm. Her temperature was 98.6°F (37°C), respira- will make the ABG results trend toward a
tory rate was 50 breaths/min, blood pressure was metabolic acidosis. This is most common in
104/54 mm Hg, and oxygen saturation was 95%. A umbilical line sampling in neonates if all he-
complete blood count performed in the afternoon parin is not removed from the line prior to
revealed a hemoglobin (Hb) of 9 g/dL, but the patient collecting the ABG sample. Comparing the
reported that she had an episode of vomiting blood in current values of pH and calculated bicarbon-
the late evening. “Did you give oxygen?” the physician ate with previous ABG results should help re-
asked the nurse. ‘’No doctor, oxygen saturation is veal this error should it occur.
95%. She called me for tachycardia; should I ask for • Air in sample: An air bubble consists of room
the cardiologist?’’ Blood samples were drawn once air, which has a PO2 of 158 mm Hg and a PCO2
more, showing a further decrease in the Hb level of approximately 0 mm Hg. PaCO2 in the blood
(6 g/dL). Blood was requested, and, in the meantime, will decrease as CO2 travels into the air bubble
colloid infusion was started. The nurse’s reluctance was in an equilibrating manner because gases travel
finally overcome, and oxygen was added at 10 L/min. from areas of high pressure to areas of low pres-
Tachycardia and dyspnea gradually subsided. sure until they are equal. Room air will change
Because this patient’s hemoglobin was so low (nor- the PaO2 in the arterial sample in an attempt to
mal values for adults are 12 to 16 g/dL), her body was equilibrate but will raise it or lower it based on
attempting to compensate by increasing cardiac output the blood sample’s starting PaO2. If the sample
and minute ventilation. She was moderately successful PaO2 is greater than 158 mm Hg, then oxygen
because the pulse oximeter reading was 95%. This is will travel from the blood into the air sample
a prime example, however, of how one piece of patient and lower the PaO2 of the blood sample. If the
data does not convey the whole patient picture. In- sample PaO2 is less than 158 mm Hg, then addi-
creasing this patient’s red blood cell count will improve tional oxygen molecules will travel into the
her ability to transport oxygen to her tissues, allowing blood sample and increase measured PaO2. To
her ventilation and heart rate to return to normal. avoid this, all air bubbles should be tapped to
the end of the syringe and pushed out of the
sample immediately after the sample is drawn.
• Venous admixture: This is an error that will
arterial puncture. Slight variations in normal ABG occur with puncture sampling, not with arte-
values exist for children of different ages. Table 1-3 rial line sampling. Peripheral venous blood
lists these variations, as well as the normal ABG has different PvO2, PvCO2, and pH values
range for adults. based on local metabolism, perfusion, and
ABG sample errors can be more pronounced in tissue and organ function. So there is no di-
pediatric samples because they are usually smaller rect correlation between any venous sample
Table 1-3 Normal Arterial Blood Gas Values When Breathing Room Air, at 37°C (14, 19–20)
_
Age pH PaCO2 (mm Hg) PaO2 (mm Hg) HCO3 (mEq/L)
12 Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care
Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care 13
Table 1-4 Techniques for Monitoring Acid-Base Status and Oxygenation in Neonatal and Pediatric
Patients
Modality Description Advantages Disadvantages
Indwelling umbilical Catheter placed in Can be easily placed Only for newborns
artery catheter one of two umbili- and offers easy access There is a risk for major
cal arteries once there complications:
Blood gases can be • Embolism (air or clot)
considered steady- • Arterial occlusion
state blood gases • Bloodstream infection
because patients
are not manipulated
during sampling
Can continuously mon-
itor blood pressure
Indwelling peripheral Catheter placed Can continuously mon- Same major complications as with
artery catheter in one of several itor blood pressure umbilical indwelling catheters when
peripheral arteries Offers easy access to placed
(radial, femoral, steady-state samples Complications also include
brachial, posterior once placed • Anaphylaxis from local
tibial arteries are all anesthetic
appropriate sites in • Arteriospasm
small children) • Vessel trauma
• Pain
• Vasovagal response
When placed incorrectly or re-
moved, a hematoma (a swelling
composed of blood under the tis-
sue that is caused by leaking from
the artery at the puncture site)
can form
Arterial puncture One-time sam- Allows access when Technique of sampling may
pling of arterial no catheter is in place cause pain in patient, which can
blood from radial, change minute ventilation and
brachial, posterior thus change blood gas values
tibial, or femoral Complications may also include
artery • Vessel trauma
• Arteriospasm
• Vasovagal response
• Emboli (air or clot)
• Arterial occlusion
Capillary sample One-time sample Low complication rate Values for PO2 not reliable
from heel or finger Easy to perform If peripheral perfusion is poor, then
Ideal technique Fair estimates of pH capillary samples are inaccurate
for chronically ill and PCO2
patients
Transcutaneous Heated skin elec- Provides continuous Much more expensive than other
monitor trode used to monitoring sampling techniques
measure PO2 and Is noninvasive Could be inaccurate with de-
PCO2 creased patient perfusion
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14 Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care
uncomfortably in her father’s arms. She is kicking the more than 170 drugs studied under one incentive
her legs and grimacing and doesn’t seem to be program within the BPCA, 159 have new pediatric
able to settle. You can hear what sounds like a labeling information, including 45 drugs with new or
loud inspiratory “wheeze,” similar to stridor. She is enhanced pediatric safety data that had not been
occasionally letting out a weak cry. Her cheeks are known before, 27 drugs with new dosing or dosing
flushed pink and her skin is warm to touch. While changes, and 50 drugs with information stating that
you begin your assessment, the nurse places Jamie they were not found to be effective in children (25).
on the ECG monitor and pulse oximeter. HR is These initiatives, however, have not closed the
180 bpm with a sinus rhythm, RR is 70 breaths/min, gap for all medications that could potentially be
and SpO2 is 90%. Blood pressure is 60/33 mm Hg. beneficial in children, and there are still many drugs
As you get your stethoscope to auscultate Jamie’s used frequently in pediatrics that are used “off-
lungs, you notice she begins to close her eyes, and label.” Off-label use (26) occurs when a medication
her mouth relaxes from the grimace. She is no longer is prescribed and delivered for an intended use,
crying, but you still hear the wheezing noise during such as age group or condition, other than that in-
inspiration. dicated in the proposed labeling. Because the FDA
cannot legally regulate how a drug is used, off-label
use is allowable. When medication delivery is initi-
ated for any indication, the following points should
apply (27):
Pharmacology
• The drug is prescribed in a manner that con-
Up until the 1990s, children were rarely in- forms to the community’s standard of care.
cluded in studies of medical treatments. As a result, • The therapy is considered reasonable; it is
only 20% to 30% of drugs approved by, Food and based on sound physiological principles and
Drug Administration (FDA) have been labeled for pathological need.
use in children. This means that the FDA did not • The therapy is safe, meaning that the clinician
have studies on how these products do or do not is aware of known side effects, there are means
work in children; what different kinds of reactions for assessing toxicity, and generally any risk is
children might have; or what the proper dose would acceptable and appropriate given the patient’s
be over the wide range of children’s ages, weights, situation.
and developmental stages. In a 2011 study in a level • Before drug dosing begins, parameters to be
II pediatric intensive care unit, researchers noted that used in monitoring for side effects and safety
24% of medications dispensed by the pharmacy were have been decided.
not approved for use in any pediatric age group, 43%
were approved for use in limited age groups, and 33% Medication Errors
were approved for use in all pediatric age groups (23). The Institute of Medicine (IOM) defines an adverse
Much is still unknown about how children respond drug event as an injury resulting from medical inter-
to drugs, biologicals such as gene therapy, and med- vention related to a drug, which can be attributable
ical devices. Strides have been taken, however, to to preventable and nonpreventable causes (28). Ad-
remedy this situation. The FDA has the authority to verse reactions to medications include those that
require pediatric studies on a drug product for the are usually unpredictable, such as unexpected allergic
product’s approved indications “if there is substan- responses, and those that are predictable, such as
tial use in the pediatric population or the product adverse effects or toxic reactions related to the phar-
would provide a meaningful therapeutic benefit— macological properties of the drug. A medication
and the absence of adequate labeling could pose sig- error is any preventable event that occurs in the
nificant risk” (24). process of ordering or delivering a medication, re-
Two initiatives have sought to encourage and sup- gardless of whether an injury occurred or the poten-
port pharmaceutical companies in pediatric drug tial for injury was present. Medication errors occur
investigation: the Best Pharmaceuticals for Children as a result of human mistakes or system flaws. For
Act (BPCA) and the Pediatric Research Equity Act adults, the reported incidence of medication errors
(PREA). These acts offer incentives to corporations is about 5% of orders written, but in pediatrics this
that include children in their testing, including exclu- number has been reported to be three times as high
sivity (patent protection that allows them to manufac- (29). A 1995 to 1999 study by the U.S. Pharmacopeia
ture a drug without competition from other suppliers (USP) Medication Errors Reporting Program
for a period of time). As of February 20, 2009, label- demonstrated a significantly increased rate of med-
ing changes had been made to more than 260 products ication error resulting in harm or death in pediatric
that were studied in children under these acts. Of patients (31%) compared with adults (13%) (30).
2831_Ch01_001-030 13/03/14 3:05 PM Page 15
Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care 15
However, potential adverse drug events—those errors • Include dose and volume when appropriate;
not causing harm—occurred in pediatric patients specify exact dosage strength to be used.
three times more often than in adults (29). • Spell out dosage units rather than using abbre-
The lack of formal pediatric indications and dos- viations (e.g., milligram or microgram rather
ing guidelines for many drugs increases the risk of than mg or μg; units rather than U).
medication errors and accounts for the significant • Stay current and knowledgeable concerning
difference in the frequency of errors in pediatric changes in medications and treatment of pedi-
patients compared with adults (29). The 1999 IOM atric conditions.
report implicates medication errors, at least in part, • Consult with a pharmacist if available.
as a direct cause of up to 98,000 patient deaths an- • Confirm patient identity before administration
nually (28) and an increase in inpatient health-care of each dose.
costs by an estimated $4,700 per hospital admission,
or approximately $2.8 million annually for a 700-bed Aerosolized Medications
teaching hospital. Children vary in weight, body sur-
The dosing and delivery of aerosolized medication
face area, and organ system maturity, which affect
is particularly challenging in children when com-
their ability to metabolize and excrete medications.
pared with adults. The differences in upper and lower
In addition, there are few standardized dosing regi-
airway anatomy affect drug deposition. There is
mens for children, with most medication dosing re-
therefore some variation in aerosolized drug dosing
quiring body weight calculations.
among institutions and potentially a lack of under-
The USP identified the following top 10 causes
standing among clinicians regarding how to dose
of pediatric medication errors for the 2-year period
aerosolized medications. This is further complicated
ending December 31, 2000:
by off-label use of many aerosolized medications.
1. Performance deficit Few respiratory medications are FDA approved for
2. Procedure or protocol not followed use in neonates, though virtually all ß-agonists and
3. Miscommunication corticosteroid formulations are approved by the
4. Inaccurate or omitted transcription FDA for use in patients older than 12 years of age
5. Improper documentation (31). Aerosolization is a preferred delivery method
6. Drug distribution system error and offers benefits over a systemic route. These in-
7. Knowledge deficit clude the following:
8. Calculation error
• Reduced systemic exposure and effects
9. Computer entry error
• Potential for lower doses compared with intra-
10. Lack of system safeguards (30)
venous or oral routes
According to the same report, the top four • Painless and generally safe administration
causes of pediatric medication errors accounted for • Ease of administration for very young children
more than 50% of all errors. Distractions, work- unable to use oral route with pills or tablets
load increase, inexperienced staff, and insufficient • Avoidance of complicating pharmacokinetic
staffing contributed to more than 70% of medica- (drug metabolism, particularly the duration of
tion errors (30). action, distribution in the body, and method
There are dozens of ways that health-care providers of excretion) and pharmacodynamic (the action
can attempt to decrease the number of adverse drug of drugs) factors in very young children
events in their institutions. Following are some actions • Rapid onset of drug action
and guidelines for decreasing pediatric medication
For most medications, pediatric dosage is calcu-
errors suggested by the AAP (29):
lated using body weight in kilograms. Aerosol dose,
• Provide a suitable work environment for safe, however, is not based on body size but rather on the
effective drug preparation. amount of drug reaching the lungs. The strategy for
• Standardize order sheets to include areas for determining dosage for inhaled medications should
patient weight, old and new allergies, prescriber be based on finding target effect. Target effect is
name, signature, and contact number. reached when a drug is dosed until the desired effect
• Establish and maintain a functional pediatric is achieved or until unacceptable side effects or tox-
formulary system with policies for drug evalua- icity occurs. Only a small portion of an aerosolized
tion, selection, and therapeutic use. drug dose actually reaches the lower airways. The
• Ensure that the weight-based dose does not aerosol particle size range most likely to be deposited
exceed the recommended adult dose. in an adult airway is 1 to 5, which is 10% to 15% of
• Ensure that calculations are correct. a delivered dose in a traditional jet nebulizer. For
• Write weight on each order written. children, decreases in airway diameter coupled with
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16 Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care
smaller tidal volumes and lower inspiratory flows External factors that can also affect the amount
suggest that smaller size aerosol particles will reach of MDI dose delivered to neonatal and pediatric pa-
the lower airways, and thus they receive a smaller tients include the following:
percentage of the ordered dose. This is further re-
• Volume of spacer chamber
duced with the addition of inflammation and secre-
• Electrostatic charge on plastic spacers
tions common in respiratory diseases and infections
• Presence and design of expiratory valves
present when children are prescribed aerosol therapy.
• Presence of an inspiratory valve
Smaller tidal volumes mean that more drug is wasted
• Amount of dead space in mask or mouthpiece
during continuous jet nebulization. Young children
are also frequently unable to follow commands and The choice of a delivery device should depend on
thus cannot perform a breath hold during aerosol the age of the patient, the drug to be administered,
delivery, shortening the amount of time an aerosol and the condition to be treated. It is also important
resides in the lower airway and decreasing absorp- for the respiratory therapist to remember that the
tion. Available data have suggested that the delivered optimal delivery device is one that a patient can and
dose could be as low as less than 1% (32) in neonates will use.
and infants, and around 2.7% in young children (33).
Although the percentage is lower, it is possible that Equipment Selection
the amount of drug per kilogram of body weight de-
livered to the lungs is still higher than that found The selection of respiratory care equipment for
with adults. Using the target effect strategy, one pediatric patients should be based on age and/or
study (34) compared a standard 2.5-mg dose of weight. It is important to choose the right-sized
albuterol with a 0.1-mg/kg dose in children 4 to equipment to best manage the airway, deliver appro-
12 years old in acute asthma and showed no differ- priate oxygen and medications, and avoid unneces-
ence in clinical improvement measured by flows, oxy- sary patient complications caused by ill-fitting or
gen saturation, and clinical score. There was also no inappropriate supplies.
difference in cardiovascular and tremor side effects. Because of the higher and more anterior glottic
To maximize the effectiveness of aerosolized drug opening, floppy epiglottis, and large tongue in chil-
delivery, the device used to deliver medications to dren younger than 3 years old, a straight (Miller)
children should be chosen carefully. Delivery of one laryngoscope blade is recommended for these pa-
drug by an inhaler may differ from delivery of tients. It elevates the distensible airway and provides
another drug by the same device. As with adult direct control of the epiglottis. Laryngoscope blade
patients, proper education is also essential when pre- sizes and types are chosen based on patient weight.
scribing an inhalation device to maximize therapy. • Size 0 Miller (straight): less than 3 kg
For parents who are struggling to correctly deliver • Size 1 Miller: 6 to 11 kg
daily inhaled medications to young children, it is dif- • Size 2 Miller: 12 to 31 kg
ficult to maintain compliance with ordered therapy. • Size 2 Macintosh (curved): 19 to 31 kg
School-age children working with the complexities • Size 3 Miller or Macintosh: greater than 31 kg
of medication delivery via dry powder inhalers and
breath-actuated metered dose inhalers may not cor- There are methods for selecting ETT sizes for
rectly manage their therapy. Pediatric compliance pediatric patients of various ages. In neonates, ETTs
with correct pressurized metered dose inhaler are selected by either gestational age (when intubat-
(pMDI) inhalation technique ranges from 39% to ing at birth) or weight (once weight is known;
67% (35). A pMDI with a mask and spacer is the see Table 1-5). Cuffless ETTs are preferred in infants.
delivery method of choice for children younger than In children older than 1 year, selection of an ETT
5 years old (35). The spacer will eliminate loss of size should be based on the following calculation:
medication in the oropharynx and stomach, thus
ETT size (mm) = (16 + age in years)/4
allowing for an effective dose delivered to the air-
ways. Crying will break a facemask-face seal in both Thus, a 6 year-old-child would require a tube size
MDI and nebulizer delivery, eliminating almost all of (16 + 6)/4, or 22/4, which is a 5.5-cm ETT. The
aerosol delivery (36). Infants seem to inhale through trachea becomes adult in size at approximately 12 to
their nose regardless of whether their mouth is 14 years of age, at which time female ETT size is 7.0
open, so care must be taken to aim aerosol delivery to 8.5 mm and male ETT size is 8.0 to 10.0 mm.
at the nose and not the mouth (33). By age 9, chil- There is no evidence to support a specific age to use
dren should be able to manage using a mouthpiece a cuffed versus an uncuffed ETT, so the AHA’s Pe-
with all devices and have a high enough inspiratory diatric Advanced Life Support recommendations
flow to activate any inspiratory demand delivery currently leave it up to the clinician whether to use a
system. cuffed or uncuffed ETT (38).
2831_Ch01_001-030 13/03/14 3:05 PM Page 17
Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care 17
18 Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care
ICU’s designated level. These classifications will evidence in making decisions about the care of the in-
be used throughout the case studies in this text to dividual patient. It means integrating individual clin-
qualify the services available to therapists and their ical expertise with the best available external clinical
patients. Table 1-7 lists the classification for NICUs, evidence from systematic research” (42). Evidence-
and Table 1-8 provides selected information for based medicine is the integration of clinical expertise,
classification of PICUs. patient values, and the best research evidence into
patient care decision making. Clinical expertise refers
Evidence-Based Medicine to a clinician’s experience, education, and skills. The
best evidence is usually found in clinically relevant re-
Dr. David Sackett, a pioneer in evidence-based med- search that has been conducted using sound method-
icine, defines evidence-based medicine as the “consci- ology (42). The steps for evidence-based practice are
entious, explicit and judicious use of current best included in Box 1-2.
Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care 19
Physical Facility
Two or more oxygen and air outlets each per bed √ √
Easy, rapid access to head of bed √ √
Television, radio, toys √ √
Physician Staff
Physician in house 24 hours a day √ √
Pediatric physician or anesthesiologist (postgraduate
year 3 or above) in house 24 hours per day √
Pediatric intensivist available in 30 minutes or less
Available within 1 hour √
Anesthesiologist
Pediatric anesthesiologist √ √
General surgeon √
Pediatric surgeon √ √
Neurosurgeon √
Pediatric neurosurgeon √ √
Otolaryngologist √
Orthopedic surgeon √
Pediatric Subspecialists √
Pediatric intensivist
Pediatric cardiologist √ √
Pediatric nephrologist √
Neonatologist √
Neurologist √ √
Radiologist √
Continued
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20 Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care
Pediatric radiologist √ √
Psychiatrist or psychologist √
√
Respiratory Therapy Staff
Supervisor responsible for training registered respiratory √ √
therapist (RRT) staff
Maintenance of equipment and quality control and review √ √
RT in house 24 hours per day assigned primarily to PICU √
RT in house 24 hours per day √ √
RT familiar with management of pediatric patients with √ √
respiratory failure
RT competent with pediatric mechanical ventilators √ √
Completion of pediatric advanced life support (PALS) √ √
training or an equivalent course (desirable but not
essential)
Respiratory Support Equipment
Bag-valve mask resuscitation devices √ √
Oxygen cylinders √ √
Respiratory gas humidifiers √ √
Air compressor √ √
Air-oxygen blenders √ √
Ventilators of all sizes for pediatric patients √ √
Inhalation therapy equipment √ √
Chest physiotherapy and suctioning √ √
Spirometers √ √
Continuous oxygen analyzers with alarms √ √
Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care 21
All published data are not equal. To help clini- Once it has gathered data on a certain question
cians and scientists, different systems have been de- and validated the research, the USPSTF assigns one
veloped to classify the quality and validity of of five letter grades (A, B, C, D, or I) to each of its
research evidence. The U.S. Preventive Services Task recommendations and provides suggestions for prac-
Force (USPSTF) is a panel of independent primary tice and levels of certainty regarding net benefit
care providers who are experts in preventive and (Table 1-9). This grading system is an example of
evidence-based medicine. The panel’s purpose is to how evidence-based practice has been implemented
conduct scientific evidence reviews of a broad range throughout the United States in a safe and effective
of clinical preventive health-care services and develop manner. Well-known pediatric recommendations
recommendations for primary care clinicians and from the USPSTF currently include screening for
health systems. The USPSTF created a “hierarchy of newborn hearing loss, sickle cell disease, childhood
research design” (44) (Box 1-3) because it recognizes obesity, speech and language delay, high blood pres-
that research design is an important component of sure, and a variety of cancers (45). The task force has
the validity of the information in a study. also made counseling recommendations for smoking
and tobacco use in children and adolescents.
Prior to the initiation of a research study, investi-
gators must meet rigorous international and federal
Box 1-3 USPSTF Hierarchy (44)
guidelines, and their research must be approved
• I: Properly conducted randomized controlled through an internal review board. This is a particu-
trial; well-conducted systematic review or meta- larly rigorous process if the study involves human
analysis of homogeneous randomized control subjects. Children are considered an especially vul-
trials nerable research subject population needing special
• II-1: Well-designed controlled trial without protection against violation of individual rights and
randomization exposure to undue risk. Early research on children
• II-2: Well-designed cohort or case-control ana- was done on those who were poor, mentally ill, insti-
lytic study tutionalized, or disabled (46). It was after discovering
• II-3: Multiple time series with or without the in- the work done by German physicians under the Nazi
tervention; dramatic results from uncontrolled regime that an international set of standards was
experiments drafted. Established in 1947 at the end of World War II
• III: Opinions of respected authorities based on and known as the Nuremberg Code, they were the
clinical experience; descriptive studies or case first regulations protecting human subjects. They are
reports; reports of expert committees international standards that outline what are now
considered to be the 10 basic principles governing the
Table 1-9 U.S. Preventive Services Task Force Grading Definitions (43)
Grade Definition Suggestions for Practice
A The USPSTF recommends the service; there is high certainty Offer or provide this service
that the net benefit is substantial
B The USPSTF recommends the service; there is high cer- Offer or provide this service
tainty that the net benefit is moderate or there is moderate
certainty that the net benefit is moderate to substantial
C The USPSTF recommends against routinely providing the Offer or provide this service only if other
service; there may be considerations that support providing considerations support the offering or
the service in an individual patient; there is at least moderate providing of the service in an individual
certainty that the net benefit is small patient
D The USPSTF recommends against the service; there is mod- Discourage the use of this service
erate or high certainty that the service has no net benefit or
that the harms outweigh the benefits
I The USPSTF concludes that the current evidence is insuffi- Read the clinical considerations section
cient to assess the balance of benefits and harms of the serv- of USPSTF Recommendation State-
ice; evidence is lacking, of poor quality, or conflicting, and the ment; if the service is offered, patients
balance of benefits and harms cannot be determined should understand the uncertainty of the
balance between benefits and harms
2831_Ch01_001-030 13/03/14 3:05 PM Page 22
22 Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care
ethical conduct of research on humans (47). Addi- you are able to move the chest, and oxygenation
tional guidelines were initially created in 1983 by the appears to have improved with your efforts. When
National Commission for the Protection of Human the on-call anesthesiologist arrives in the room a few
Subjects of Biomedical and Behavioral Research, minutes later, the physician leaves Jamie’s bedside
which further protect the interests, health, and to consult with the pediatric intensivist at the chil-
safety of children involved in medical research (46). dren’s hospital. You and the anesthesiologist decide
The current guidelines reside with the U.S. Depart- to place a nasogastric tube to eliminate gastric dis-
ment of Health and Human Services (48). These tention and use cricoid pressure to minimize any
additional restrictions have resulted in significantly further gastric insufflation. The anesthesiologist
less published research in children compared to determines that if at any point manual ventilation
adults. For clinicians, this means a great deal more becomes difficult for you, the next step in the airway
deliberation when evaluating smaller amounts of management plan will be to place an endotracheal
research available to guide health-care decisions. tube.
Often evidence-based practice in adults is trans- You reassess Jamie and note that her HR is now
ferred to children without assurance that results 178 bpm, blood pressure is 55/30 mm Hg, and SpO2
would be comparable in a different age population. is 97%. Her skin is still flushed, and she seems to
Care must be taken to use the available evidence ef- be developing a rash over her face and chest. You
fectively and make informed decisions about patient don’t hear inspiratory wheezing when you squeeze
care. Involving the child, parents, and other clinical the resuscitation bag, and she isn’t taking any spon-
team members in the decision-making process can taneous breaths. The pediatric transport team has
assist in making the best decision for the patient. just arrived to take over Jamie’s care.
Multiple-Choice Questions
1. Why should all respiratory therapists need to 2. Why are pediatric airways more difficult to
be able to care for pediatric patients? intubate than adult airways?
a. Every hospital has at least one pediatric a. Pediatric patients have a large tongue in rela-
unit, and therefore there will always be tion to the oropharynx.
patients for whom to care. b. The cricoid ring is the smallest portion of
b. Children cannot communicate their symp- the airway.
toms to health-care providers. c. Pediatric patients have large tonsils and
c. Pediatric critical events are frequently respi- adenoids.
ratory in origin and thus need the services d. Pediatric patients have a higher and more
of a skilled respiratory therapist. anterior epiglottis.
d. Inhaled medications have been approved
for use in all age groups, so therapists must
be competent in performing complex dose
calculations for aerosolized medications.
2831_Ch01_001-030 13/03/14 3:05 PM Page 23
Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care 23
24 Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care
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42. Sackett D. Evidence-based medicine—what it is and what dations. http://www.uspreventiveservicestaskforce.org/
it isn’t. Clin Orthop Relat Res. 2007;455:3-5. http://www. tfchildcat.htm. Accessed January 28, 2011.
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45. United States Public Health Service. United States Preven-
tive Services Task Force. Child and adolescent recommen-
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26 Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care
16 16
7 AGE (MONTHS)
kg lb
12 15 18 21 24 27 30 33 36
14
6 Mother’s Stature Gestational
W Father’s Stature Age: Weeks Comment
E 12
Date Age Weight Length Head Circ.
I 5 Birth
G 10
H
T
4
8
3
6
2
lb kg
Birth 3 6 9
Figure 1-4 Boys Birth to 36 Months: Length-for-Age and Weight-for-Age Percentiles.
(From: Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: methods and
development. National Center for Health Statistics. Vital Health Stat 2002;11[246].)
2831_Ch01_001-030 13/03/14 3:05 PM Page 27
Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care 27
16 16
7 AGE (MONTHS)
kg lb
12 15 18 21 24 27 30 33 36
14
6 Mother’s Stature Gestational
W Father’s Stature Age: Weeks Comment
E 12
Date Age Weight Length Head Circ.
I 5 Birth
G 10
H
T
4
8
3
6
2
lb kg
Birth 3 6 9
Figure 1-5 Girls Birth to 36 Months: Length-for-Age and Weight-for-Age Percentiles.
(From: Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: methods and
development. National Center for Health Statistics. Vital Health Stat 2002;11[246].)
2831_Ch01_001-030 13/03/14 3:05 PM Page 28
28 Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care
2 to 20 years: Boys
Stature-for-age and Weight-for-age percentiles
12 13 14 15 16 17 18 19 20
Mother’s Stature Father’s Stature cm in
Date Age Weight Stature BMI*
AGE (YEARS) 76
95
190
74
90
185 S
75
72
180 T
50 70 A
175 T
25 68 U
170 R
10 66
165 E
in cm 3 4 5 6 7 8 9 10 11 5
64
160 160
62 62
155 155
S 60 60
T 150 150
A 58
T 145
U 56
140 105 230
R
54
E 135 100 220
52
130 95 95 210
50
125 90 200
90
48 190
120 85
46 180
115 80
75
44 170
110 75
42 160
105 50 70
150 W
40
100 65 140 E
25
38 I
95 60 130 G
10
36 90 5 H
55 120
T
34 85 50 110
32 80 45 100
30
40 90
80 35 35 80
W 70 70
30 30
E 60 60
I 25 25
G 50 50
H 20 20
40 40
T
15 15
30 30
10 10
lb kg AGE (YEARS) kg lb
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Figure 1-6 Boys 2 to 20 Years: Length-for-Age and Weight-for-Age Percentiles. (From:
Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: methods and develop-
ment. National Center for Health Statistics. Vital Health Stat 2002;11[246].)
2831_Ch01_001-030 13/03/14 3:05 PM Page 29
Chapter One ■ Making Sense of Caring for Kids: A Different Approach to Respiratory Care 29
2 to 20 years: Girls
Stature-for-age and Weight-for-age percentiles
12 13 14 15 16 17 18 19 20
Mother’s Stature Father’s Stature cm in
Date Age Weight Stature BMI*
AGE (YEARS) 76
190
74
185 S
72
180 T
70 A
95
175 T
90
68 U
170 R
75 66
165 E
in cm 3 4 5 6 7 8 9 10 11 50
64
160 25 160
62 62
155 10 155
60 5 60
150 150
58
145
56
140 105 230
54
S 135 100 220
T 52
A 130 95 210
50
T 125 90 200
U
48 190
R 120 85
E 95 180
46
115 80
44 170
110 90 75
42 160
105 70
150 W
40 75
100 65 140 E
38 I
95 60 130 G
50
36 90 H
55 120
25 T
34 85 50 110
10
32 80
5
45 100
30
40 90
80 35 35 80
W 70 70
30 30
E 60 60
I 25 25
G 50 50
H 20 20
40 40
T
15 15
30 30
10 10
lb kg AGE (YEARS) kg lb
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Figure 1-7 Girls 2 to 20 Years: Length-for-Age and Weight-for-Age Percentiles. (From:
Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: methods and develop-
ment. National Center for Health Statistics. Vital Health Stat 2002;11[246].)
2831_Ch01_001-030 13/03/14 3:05 PM Page 30
2831_Ch02_031-044 13/03/14 3:17 PM Page 31
Section One
Chapter 2
Fetal Cardiopulmonary
Development
Chapter Outline Key Terms
Chapter Objectives Acinar units
Key Terms Alveolar phase
Ann Wilson Canalicular phase
Determining Gestational Age Cerebrum
Fetal Lung Development Chorionic villi
Embryonic Phase Ductus arteriosus
Pseudoglandular Phase Ductus venosus
Canalicular Phase Embryonic phase
Saccular Phase Endoderm
Alveolar Phase Fetal circulation
Fetal Cardiac Development Fetal lung fluid
Fetal Neurological Development Foramen ovale
Fetal Circulation Germinal matrix
Changes to Fetal Circulation at Gestation
Delivery Gyri
Assessing Fetal Lung Maturity Mesenchyme
Tocolytics and Glucocorticoids Mesoderm
During Preterm Labor Morbidity
Implications of Development on Myocardial cells
Neonatal Course Phosphatidylcholine (PC)
Critical Thinking Questions: Phosphatidylglycerol (PG)
Ann Wilson Preterm
Case Studies and Critical Thinking Pseudoglandular phase
Questions Saccular phase
Case 1: Jody Hayworth Saccules
Case 2: Maria Gonzalez Septa
Multiple-Choice Questions Sulci
References Surfactant
Tocolytic drugs
Type I cells
Type II cells
Viability
31
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Chapter Objectives
After reading this chapter, you will be able to:
1. Identify two ways to calculate gestational age.
2. Compare the structure of the fetal lung at the embryonic, pseudoglandular, canalicular, saccular, and
alveolar pulmonary development stages.
3. Describe the anatomical milestones for the embryonic, pseudoglandular, canalicular, saccular, and alveolar
pulmonary development stages.
4. Explain the purpose of fetal lung fluid and its role in fetal development.
5. Describe the benefits of pulmonary surfactant, and note the gestational age of its initial appearance in
the fetal lung.
6. Illustrate the timeline of fetal cardiac development.
7. Define the germinal matrix and describe its function in fetal neurological development.
8. Identify the structures and ducts that allow for fetal circulation.
9. Describe three changes to fetal circulation that occur during a normal delivery to assist the newborn in
transition to extrauterine life.
10. Given a marginally premature fetus, select a method to assess fetal lung maturity.
11. Given a specific gestational age, describe the likelihood for survivability based on pulmonary, cardiac,
and neurological development.
T
he human lungs serve the critical purpose of
respiration, providing necessary oxygen to 1. Conception: First 2 weeks of pregnancy, when
functioning tissues and preventing hypoxia the female ovum and male sperm unite
and cell death. At no time is the importance of this 2. Embryonic stage: Pregnancy weeks 3 to 12,
function more evident than in the first few moments encompassing 4 to 8 weeks of embryo devel-
of life, when a newborn’s first breath starts a cascade opment. This is when the major organs such
of physiological changes to transition the infant to as the central nervous system and heart begin
life outside the uterus. For the newborn to take an development.
effective first breath, the lungs must complete devel- 3. Fetal development stage: Encompasses the
opment during the period from conception to birth, remaining weeks 13 to 40 for a full-term
2831_Ch02_031-044 13/03/14 3:17 PM Page 33
Embryonic Conception to week 6 Right and left lung buds arise from esophagus
Trachea forms
Diaphragm completing development
Pseudoglandular Weeks 7–16 Airways continue to branch
Hard and soft palates grow
Pulmonary vasculature develops
Cilia and cartilage appear in large conducting airways
Canalicular Weeks 17–26 Capillary network forms
Airways complete branching
Acinar units first seen
Immature surfactant noted
Saccular Weeks 27–35/36 Development of alveolar saccules
End of structural lung formation
Alveolar Week 36–term Alveolar proliferation
By birth ~50 million alveoli developed
2831_Ch02_031-044 13/03/14 3:17 PM Page 34
(the caudal portion) dilates to form the early ventri- 7 weeks’ gestation, beginning with a neural plate
cle. The bottom portion of the tube develops in that develops into a neural tube with an opening at
three distinct areas: One portion develops into the each end. This new human brainstem continues to
body of the right ventricle; another portion is called grow, forming the medulla, pons, and midbrain. The
the truncus arteriosus, which develops into the aortic medulla mediates arousal, breathing, heart rate, and
root and ascending aorta; and the midportion con- gross movement of the body and head, so that by
nects the first two portions. During this time, the week 9, the fetus will make spontaneous movements
ventricles are positioned above the atria, but the and 1 week later takes its first practice breath. By
rapid growth of the heart tube forces it to bend week 25, a fetus will display stimulus-induced heart
upon itself. The ventricles will rotate into the correct rate accelerations. The pons mediates arousal, body
anatomical position by bending into an S shape and movements, equilibrium, and perception of sound
moving down and to the right. The atria are then lo- vibration; from around weeks 20 to 27, the fetus re-
cated behind and above the primitive ventricles and sponds with arousal and body movements when
split into right and left at the center of the S shape sounds are delivered to the maternal abdomen. The
around day 28. At about the same time, a single midbrain auditory and visual system is the last to
pulmonary artery grows from the outer wall of the mature: In conjunction with the lower brainstem it
left atrium. By early in week 8 of development, the makes fine auditory discriminations, and around
truncus arteriosus has completely separated into week 36 it reacts to sound with fetal heart rate accel-
the aorta and pulmonary trunk. During develop- erations, head turning, and eye movements.
ment, there are six pairs of aortic arches that supply Within the developing brain, a germinal matrix is
blood to the developing brain. This creates a vascu- formed to assist in rapid cellular formation. It first
lar ring that surrounds the developing esophagus appears around 9 weeks’ gestation, and its volume
and trachea. As the fetus develops, about half of the increases exponentially until week 23 (12). This vol-
vascular system regresses, leaving the aortic arch, ume remains high until 28 weeks’ gestation, when it
innominate artery, ductus arteriosus (which is de- begins to decrease sharply. It begins to disappear
scribed in the section on fetal circulation), pul- around 34 weeks and is no longer present in a full-
monary arteries, descending aorta, and subclavian term neonate. The germinal matrix is a weakly sup-
arteries. ported and highly vascularized area at the surface
Between weeks 8 and 10, the valves begin to form of the lateral ventricles and is prone to hypoxic-
between the atria and ventricles and at the root of ischemic injury. The vessels of the germinal matrix
the pulmonary artery and aorta. Around week 9 or are irregular and are prone to rupture. In addition to
10, the heart begins biphasic pumping (11), similar the structural instability of the germinal matrix, an
to the function of an adult heart, and anatomical de- increase in systemic blood pressure in a premature
velopment of the heart is complete. See Figure 2-3 infant will increase cerebral blood flow, which can
for a diagram of the embryological development of rupture the germinal matrix. This leads to a high in-
the heart. Deviations in cardiac development will cidence of intraventricular hemorrhage in premature
lead to congenital cardiac defects, many of which are neonates. Damage to the germinal matrix vessels
described in detail in Chapters 11 and 12. may result in impairment of nerve and brain growth.
High arterial carbon dioxide levels (hypercarbia) can
Fetal Neurological Development also contribute to the risk of intraventricular hem-
orrhage. Intraventricular hemorrhage is described in
The neural system is the most complex structure more detail in Chapter 8.
within the embryo. Neural system development is Cerebral development also helps clinicians deter-
one of the earliest to begin and is the last to be com- mine fetal viability, or capacity to live. The cerebrum
pleted after birth. Its development begins at around is the largest portion of the brain, consisting of two
Right Aorta
Truncus
ventricle Pulmonary
Arterial arteriosus
trunk
Heart Left
tube Ventricles ventricle Atrium
Umbilical
Umbilical
vein
vein
Umbilical
arteries
Umbilical
arteries
Placenta
This small volume of blood functions to feed the in the aorta and carotid artery regulate ventilation
growing lung tissue. Without an escape, the remain- in humans. As the fetus descends into the birth
ing blood volume would back up dangerously into canal, he or she is cut off from the placenta. This
the right side of the heart, increasing its pressure. In causes a drop in the partial pressure of oxygen in
addition to the foramen ovale, excess blood that en- the blood, or PaO2 (commonly referred to as as-
ters the pulmonary system via the pulmonary artery phyxia), which is detected by the chemoreceptors
is vented through the ductus arteriosus to the aorta, and causes a chemical message to be sent to the
just after the right subclavian branch. Blood flowing brainstem to increase ventilation. The thorax is
through the ductus arteriosus will bypass the left side compressed through the birth canal during delivery,
of the heart. Both the shunted blood and that from then expands to normal size at delivery, creating a
the left ventricle travel through the aorta, perfusing negative intrathoracic pressure and causing air to
the upper and lower portions of the body. A portion enter the lungs. The environmental changes from a
passes through the umbilical arteries, which arise dark and warm uterus to a bright, cold, and noisy
from the iliac arteries in the pelvis, and flows back to delivery room and the physical stimulation of the
the placenta. infant by handling will trigger his or her crying
reflex.
Changes to Fetal Circulation at Delivery Fetuses begin “practice breathing” during the
second trimester (weeks 12 to 24) but refine the
The change from intrauterine to extrauterine circu- technique in the last 10 weeks of gestation. At de-
lation occurs within minutes to hours after birth, and livery, the alveoli have no air in them. Fetal lung
the first breaths a newborn takes help to make this fluid is secreted by type II alveolar cells to stabilize
transition possible. The first breath has to overcome the structure of the lung in utero. In late gestation
the surface forces of the lung, and it helps create a and shortly before birth, fetal lungs convert from
gaseous functional residual capacity (FRC) to re- fluid secretion to fluid reabsorption. Epinephrine
place the fetal lung fluid initially held there. released during labor inhibits the chloride channel
There are several factors at play during delivery within type II cells, which causes the secretion of
that stimulate a newborn to breathe. Chemoreceptors lung fluid. It simultaneously stimulates sodium
2831_Ch02_031-044 13/03/14 3:17 PM Page 39
● Special Populations 2-1 L/S ratio test, but only 42% list it as their test of
choice for measuring FLM (21). The reasoning is
Gestational Diabetes that it is a costly test with a high turnaround time
Gestational diabetes has many implications for the (5-6 hours) (22), and it requires highly trained labo-
health of mother and fetus, but of particular importance ratory personnel to perform.
is FLM. When glucose control is poor, the rate of sur-
factant delay is increased (19). At full term, the lung still PG Presence
seems to have matured, but prior to term, mothers PG appears first in amniotic fluid at around 35 weeks’
with gestational diabetes are more likely to have FLM gestation, when mature surfactant is produced, and
tests that show immature lungs when compared with levels increase at 37 to 40 weeks. The laboratory will
expected results. This is complicated further by the fact report PG as either “present” or “absent,” making it
that fetal size is usually larger than expected when a useful marker late in pregnancy. This test is a good
mothers have gestational diabetes, giving false security predictor of mature lungs, but it is a poorer predictor
to clinicians who think that a larger baby means more of occurrence of RDS when the result is “absent.” A
mature lungs. literature review found that in 25% to 63% of cases
of an absent PG test, neonates developed RDS (21).
However, this is the only currently available test that
is not affected by sample contamination by blood
Several tests for FLM are currently available,
or meconium, which are common contaminants in
including the following:
amniotic fluid sampling.
• Lung profile test, consisting of
• Lecithin-sphingomyelin (L/S) ratio Shake Test
• Presence of PG The shake test, also known as the foam test, is a
• Shake test (also known as the foam test) simple test that can be used to indicate the need for
• Surfactant-albumin (S/A) ratio (also known as further testing. A small sample of amniotic fluid is
the TDx Fetal Lung Maturity test or FP test) mixed with ethanol and shaken for 15 seconds. It is
• Lamellar body concentration left to sit for 15 minutes, and then a reading is
These tests look at various characteristics of am- taken. The presence of a ring of bubbles in the
niotic fluid and fetal lung fluid. Fetal lung fluid leaves ethanol shows that there is enough lecithin present
the lung via the trachea and is excreted through the to create stable foam. A negative result (no foam
mouth, mixing with amniotic fluid. It is because of present) indicates that an L/S ratio should be
this mechanism that obtaining a sample of amniotic performed.
fluid can help assess lung maturity. No test has been
conclusively found to be superior, so the type of test SIA Ratio
is usually chosen based on physician or institution The S/A ratio is more widely known by its brand
preference. name, TDx Fetal Lung Maturity test. It is FDA
Lung Profile Test cleared and commercially available from Abbott
Diagnostics (Abbott Park, Ill.). The test operates on
L/S Ratio the principle of fluorescence polarization (hence, it
Developed in 1971, the L/S ratio is the most long- is also sometimes known as the FP test), and it is per-
standing and well-known FLM test. It tests the ratio formed on the company’s TDx instrument platforms.
of lecithin, a principal active component of surfac- It measures the relative concentrations of surfactant
tant, also known as phosphatidylcholine (PC), to the and albumin (milligrams of surfactant per gram of
level of sphingomyelin, a phospholipid found mostly albumin). This test provides a simple, automated,
in body tissues other than the lungs. Lecithin levels rapid test that is widely available; requires less tech-
in the amniotic fluid increase in late gestation, nical expertise than the does the L/S ratio; varies
whereas sphingomyelin remains constant throughout minimally between laboratories; and requires only a
pregnancy. An L/S ratio at 31 to 32 weeks’ gestation small volume of amniotic fluid, typically 1 mL. A re-
is usually around 1:1, and it increases to 2:1 by sult showing more than 55 mg of surfactant per 1 g
35 weeks’ gestation. An L/S ratio of 2:1 means that of albumin is considered mature; values of less than
the lungs are mature, and there is only a 2% chance 40 mg surfactant per 1 g albumin are considered im-
the fetus will develop RDS if delivered. An L/S ratio mature; and values of 40 mg to 54 mg surfactant per
of 1.5:1 predicts a 50% chance of RDS if the fetus is 1 g albumin are considered indeterminate. A 2010
delivered, whereas a less than 1.5:1 ratio predicts a survey showed that S/A ratio was the test of choice
73% chance of RDS if delivered (20). When sur- for 62% of physicians, and it was the test ordered
veyed, 99% of obstetricians were familiar with the clinically 72% of the time (21).
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Table 2-3 Developmental Progress for Select ■■ Critical Thinking Questions: Ann Wilson
Gestational Ages 1. What do you expect the implications would have
Gestational been had Ann’s estimated gestational age had
Age (weeks) Milestones been 28 weeks instead of 34?
2. How do you think the physician’s decision would
24 Structural airways developing, respira-
tory bronchioles still developing have changed if the results of the FLM tests had
First appearance of immature surfactant been as follows?
(phosphatidylcholine); easily inactivated a. S/A ratio 40 mg surfactant to 1 mg albumin
Capillaries close enough to begin gas b. L/S ratio 1.5:1
exchange; beginning of acinar unit c. PG presence negative
3. What may have caused this patient’s preterm
development
Alveolar-capillary membrane thicker, labor, based on your understanding of the risk
may be several cell layers thick factors and current patient history?
4. After delivery, what might you be able to assess
Cerebral sulci and gyri beginning to form
Physiological response to physical regarding the infant to determine the accuracy of
stimulation the FLM test results?
Germinal matrix present; susceptible to in-
jury from changes in cerebral blood flow
28 End of structural lung formation
Alveolar saccules in development
Immature surfactant present ◗● Case Studies and Critical
Physiological response to physical
stimulation
Thinking Questions
Volume of germinal matrix high
■ Case 1: Jody Hayworth
32 Increase in number of acinar units You are working the night shift in a 20-bed level IIIC
Immature surfactant present NICU and carrying the delivery room pager. You are
Volume of germinal matrix will begin to occupied with discharge planning rounds for the
diminish over next few weeks following morning when labor and delivery pages
36 Mature pulmonary surfactant (with PG) you to attend a 26-week-gestation delivery. On the
should be present walk over to labor and delivery, you discuss the
Auditory and visual systems in cere- patient’s history with the physician. Jody Hayworth
brum developed is 16 years old, and this is her first pregnancy. She
Germinal matrix volume decreasing has been in the hospital on bed rest for 5 days
sharply for premature rupture of membranes. She denies
40 ~50 million alveoli developed drinking, smoking, or drug use. She has had no
Mature surfactant present fever and no recent pain. When you arrive at labor
Fetal lung fluid volume decreasing and delivery, Jody is about to begin pushing. You
Fetus practice breathing review her current status with her nurse. She re-
Germinal matrix disappeared ceived a regimen of indomethacin and magnesium
sulfate the previous morning, but it didn’t stop
labor. She received three doses of betamethasone
(a glucocorticoid) beginning at admission to the
■ ■ Anne gives birth to a baby boy 14 hours after hospital.
the lung profile results were shared with the neonatal
team. Baby boy (BB) Wilson was born active and cry- • Should Jody have had FLM testing? Why or
ing and only required supportive care in the delivery why not?
room. He was admitted to the NICU, and when you • How likely is it that Jody’s newborn will have
arrive to work you note that he is now 5 hours old and RDS?
requires no respiratory support. His chest radiograph • Currently, in what stage of pulmonary devel-
was clear, with no evidence of lung disease. He is opment is the fetus?
sleeping comfortably, and Anne has been able to visit • What problems may arise from this fetus’s
several times since he was born. He will spend the current neurological development?
next several days attempting to feed, and if he is able • Do you think Jody’s newborn will have surfac-
to gain weight and shows no additional signs of respi- tant deficiency?
ratory immaturity, he will be discharged home.
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■ Case 2: Maria Gonzalez was evident. Fetal age was estimated at 35 weeks’
It is the end of the day shift at a rural community gestation during prenatal visits and by ultrasound
hospital. You are called to a 33-week-gestation bipariatal diameter. During the ultrasound, an am-
delivery. Maria Gonzalez is 42 years old and is niocentesis was also obtained, and a lung profile
about to deliver her fourth child. She was just was sent for analysis. L/S ratio is 1.5:1, and PG is
diagnosed last week with gestational diabetes. absent.
Maria was in a minor car accident today during
• What does the lung profile tell you about
the morning rush hour. She felt some abdominal
Maria’s baby’s lung maturity?
cramping after the accident and was transported
• Currently, in what stage of pulmonary devel-
to the hospital via ambulance. She has had no
opment is the fetus?
bleeding, leaking of amniotic fluid, or obvious
• Are you concerned about the motor vehicle
trauma, but her cramping was diagnosed as
accident? If so, specifically what concerns
preterm contractions. Attempts were made
you?
to stop labor using indomethacin, but without
• Why do you think Maria’s fetus is measuring
success. A fetal ultrasound was done to assess
larger than her predicted gestational age?
any physical injury from the accident, but none
Multiple-Choice Questions
1. What would be the best method to calculate b. Develops gyri and sulci on the surface of the
gestational age for a woman who thinks it has cerebellum
been about 2 months since her last menstrual c. Regulates the auditory and visual systems of
period, but she doesn’t remember an exact the midbrain
date? d. Assists in rapid cellular formation during
a. Crown-to-rump measurement fetal development
b. Biparietal diameter 6. At what gestational age would a fetus display
c. Abdominal circumference the following: immature surfactant, functional
d. Femur length alveolar-capillary membranes, fully developed
2. During which fetal lung development stage heart, and gyri and sulci in the cerebrum?
does surfactant first appear? a. 10 weeks
a. Pseudoglandular b. 20 weeks
b. Canalicular c. 30 weeks
c. Saccular d. 40 weeks
d. Alveolar 7. Returning from the placenta, which is the correct
3. Fetal lung fluid is designed to: order of blood flow through fetal circulation?
a. Maintain patency of airways and alveoli a. Umbilical artery, ductus arteriosus, ductus
during growth. venosus, umbilical vein
b. Assist in newborns taking their first breath. b. Umbilical vein, ductus venosus, foramen
c. Decrease surface tension. ovale, umbilical artery
d. Provide nutrients for growing type I and c. Umbilical vein, ductus venosus, ductus arte-
type II cells. riosus, foramen ovale, umbilical artery
4. The benefits of alveolar surfactant include: d. Umbilical artery, ductus arteriosus, foramen
I. Lowering surface tension. ovale, ductus venosus, umbilical vein
II. Lowering airway resistance. 8. Which of the following is not an event that oc-
III. Preventing alveolar collapse. curs around the time of delivery that stimulates
IV. Higher lung compliance. breathing in newborns?
a. I, II a. Aortic chemoreceptors responding to
b. I, IV hypoxemia
c. I, II, III b. Reabsorption of fetal lung fluid in utero
d. I, III, IV c. Negative intrathoracic pressure just after
5. What is the function of the germinal matrix in passing through the birth canal
cerebral development? d. Environmental stimulation (e.g., delivery
a. Adds cellular stability to prevent intraven- room noises, bright lights, cold room)
tricular hemorrhage
2831_Ch02_031-044 13/03/14 3:17 PM Page 44
9. Which of the following patients has the lowest glucocorticoids to accelerate fetal lung
risk for RDS? development?
a. 24 weeks’ gestation a. Within 24 hours of delivery
b. 36 weeks’ gestation with L/S ratio of 2:1 b. Not recommended before 35 weeks’ gestation
c. 38 weeks’ gestation with S/A ratio of 45 mg c. More than 24 hours but not more than 7 days
surfactant per 1 g albumin before delivery
d. 31 weeks’ gestation d. Most effective at less than 26 weeks’ gestation
10. Which of the following is the recommended
treatment regimen for dosing with prenatal
Chapter 3
Resuscitation of
the Newborn
During Transition to
Extrauterine Life Theodora A. Stavroudis, MD
Chapter Objectives
After reading this chapter, you will be able to:
1. Describe the three stages of labor.
2. Identify two methods used in assessing fetal well-being during labor and delivery.
3. Describe the normal transition to the extrauterine world.
4. Name antepartum and intrapartum risk factors associated with the need for neonatal resuscitation.
5. List the equipment needed for the resuscitation of the newborn.
6. List the three questions of rapid assessment at the time of birth.
7. Discuss measures that must be taken to ensure that adequate warmth is being provided to the newborn
in the delivery room.
8. Determine when to provide oxygen and/or positive pressure ventilation during an infant’s transition to
extrauterine life.
9. Identify when to administer chest compressions and epinephrine to a newborn according to the Neonatal
Resuscitation Program (NRP) guidelines.
10. Discuss special considerations during neonatal resuscitations, such as when not to initiate or stop
resuscitation measures and how to take care of newborns with congenital anomalies.
11. Assign Apgar scores to an infant during neonatal resuscitation.
I
n 2010, 3.99 million babies were born in the trauterine world, and it is divided into three stages
United States (1). About 90% of these babies (3). The first stage of labor is the process by which
made the transition to extrauterine life without the cervix reaches full dilatation to 10 cm. It is made
difficulty, and fewer than 1% needed extensive resus- up of three phases: the latent phase, the active phase,
citative measures to survive (2). This translates to and the deceleration phase. In the latent phase, con-
about 400,000 newborns who required some type tractions become more coordinated, and the cervix
of neonatal resuscitation and 40,000 who required reaches 4 cm dilatation. The latent phase can last as
extensive resuscitation. There are specific risk factors long as 12 hours for women who have given birth
and signs present prior to delivery that can help previously (multiparous) and as long as 20 hours for
obstetric teams identify which newborns will require women who have never given birth (nulliparous).
resuscitation, including prenatal or perinatal risk fac- Membranes may spontaneously rupture during this
tors or fetal heart rate (FHR) changes during labor. phase of labor. In the active phase, the cervix dilates
However, the obstetric team must always be prepared to approximately 8 to 9 cm, and it is the phase of the
to resuscitate an infant because even newborns with most rapid cervical dilatation. It lasts about 5 hours
no risk factors may require it. The outcomes of thou- in nulliparous women and about 2 hours in multi-
sands of newborn lives can be improved by appro- parous women. Finally, in the deceleration phase,
priate assessment during delivery and rapid neonatal also known as transition, the cervix reaches complete
resuscitation, which can prevent injury from birth dilatation, and the presenting part of the fetus
2831_Ch03_045-064 13/03/14 3:16 PM Page 47
Head compression
A
Detached
placenta
B
Umbilical cord
compression
Fetal scalp
monitor
D
Figure 3-1 Fetal Heart Tracings
physiological events during the transitional period placenta. It is extremely important that RTs recog-
include the following: nize a newborn at risk for interruption of normal
transitional physiology and in need of resuscita-
• Clearance of fetal lung fluid
tion. Box 3-1 presents a list of antepartum (prior
• Filling of the lungs with air
to labor and delivery) and intrapartum (during
• Secretion of surfactant
labor and delivery) risk factors associated with
• Establishment of functional residual capacity
neonatal depression and asphyxia. These factors
• Vasodilatation of the pulmonary vasculature
may interfere with a newborn’s ability to do the
and decrease in pulmonary vascular resistance
following:
• Removal of the placenta and increase in sys-
temic vascular resistance • Fill the lungs with air
• Functional closure of two fetal channels • Release surfactant
(foramen ovale and ductus arteriosus) • Maintain cardiac output and systemic blood
• Increase in pulmonary blood flow pressure
• Maintain sufficient oxygen-carrying capacity
Anticipating Neonatal Resuscitation • Vasodilate the pulmonary vascular bed
A newborn may have difficulty transitioning to ex- Problems with any or all of these functions prevent
trauterine life for a variety of reasons, including oxygen from reaching body tissues and may warrant
problems with fetal health, maternal health, or the the need for newborn resuscitation.
2831_Ch03_045-064 13/03/14 3:16 PM Page 49
Anticipating the need for possible resuscitation The Neonatal Resuscitation Program
and assembling the appropriate personnel in the de-
Every year, an estimated 4 million infants around the
livery room are key elements in preparing for resus-
world die during the neonatal period, and perinatal
citation. Communicating with the obstetrics team
depression/birth asphyxia accounts for approxi-
regarding the antepartum and intrapartum risk fac-
mately 23% of neonatal mortality. It is postulated
tors and the timing of birth is essential for the RT
that effective resuscitation of the newborn baby
to ensure that the necessary neonatal team responds
could prevent and reduce approximately 42% of
in a timely and effective manner. Birthing centers
these deaths (8, 9). In 1987, the American Academy
typically develop internal protocols indicating the
of Pediatrics and the American Heart Association
graded response needed for neonatal resuscitation.
developed the Neonatal Resuscitation Program
However, there should be at least one person who is
(NRP), an educational program designed to train cli-
skilled in providing neonatal resuscitation at every
nicians in newborn resuscitation methods (1). More
delivery, with primary responsibility for the new-
recently, behavioral skills such as teamwork and
born. In addition, the personnel assembled in the
communication have been cited to be critically im-
delivery room should be capable of working to-
portant to the effective resuscitation of the newborn
gether as a team (7).
(7, 10, 11).
Although the majority of newborns do not re-
■ ■ The pediatric delivery room team (pediatrician, quire assistance as they transition to extrauterine
RT, and neonatal nurse) has now assembled in labor life, it is estimated that approximately 10% require
room 3, and the doctor asks you to prepare and set some assistance to breathe, and fewer than 1% re-
up the equipment for neonatal resuscitation. As you quire extensive resuscitation measures (1). Thus, it
gather your equipment, the baby is delivered. You is critical for the neonatal RT to be trained in
hear a spontaneous cry as the obstetrician brings NRP. An RT must be able to prepare for resusci-
the newborn to the radiant heat warmer. tation of the newborn, perform rapid assessment
of the newborn at the time of delivery, and provide
2831_Ch03_045-064 13/03/14 3:16 PM Page 50
the necessary interventions to assist the newborn linen under a radiant heat warmer, other techniques
in transitioning to extrauterine life. used to prevent heat loss and achieve normothermia
Resuscitation begins with anticipating the man- (12) include the following (10):
agement needs of the newborn during resuscita-
• Prewarming the delivery room to 26°C
tion. The two major components of preparation
• Prewarming the linens
are assembling the equipment for resuscitation
• Drying and swaddling
and providing an environment to prevent neonatal
• Offering skin-to-skin contact with the mother
heat loss.
and covering both with a blanket
Preparation and Equipment • Placing a hat on the newborn’s head
• Placing the baby on a thermal warming mattress
Having the proper equipment available and ready at
• Covering the baby in plastic wrapping (food
the time of delivery is a critical step in the resuscita-
or medical grade, heat-resistant plastic) if he
tion of the newborn. Often, preparing the equipment
or she weighs less than 1,500 grams (Special
is the RT’s responsibility. An area of the deliv-
Population 3-1)
ery room should be designated for the resusci-
tation of the newborn and should be supplied with Recent randomized, controlled, multicenter trials
the necessary equipment for suctioning, bag-mask have shown that induced hypothermia of newborns
ventilating, intubating, administering medications, 36 weeks’ gestational age or older with moderate to
and providing warmth to the newborn. A checklist severe hypoxic-ischemic encephalopathy may protect
of neonatal resuscitation equipment and supplies is against brain injury (12–14). Strict criteria are used
provided in Box 3-2. for eligibility, and induction of hypothermia must
begin within 6 hours after birth. Infants with evi-
Temperature Regulation dence of moderate to severe hypoxic-ischemic en-
Preventing heat loss in the newborn is essential to cephalopathy (acute or subacute brain injury as a
providing effective resuscitation and decreasing mor- result of hypoxia and acidosis) should be offered
bidity. In addition to drying the newborn with a dry therapeutic hypothermia in a timely manner, and
Figure 3-2 NRP Algorithm (Used with permission of the American Academy of Pediatrics, Textbook of
Neonatal Resuscitation, 6th ed, 2011.)
Beats/min Gasps/min
60
■ ■ Baby girl (BG) Zacharian is brought to the radiant
mm Hg
40
20 Blood pressure warmer and is placed on her side by the obstetri-
0 cian. The doctor begins to dry the baby as you bulb
Time
Figure 3-3 Primary Versus Secondary Apnea suction her mouth and then her nose. Meconium
2831_Ch03_045-064 13/03/14 3:16 PM Page 54
Noninvasive Ventilation
Assisted ventilation should be given at a rate of 40
to 60 breaths per minute to achieve a heart rate
B greater than 100 bpm and movement of the chest
wall. Though optimal pressure, inflating time, and
flow rate are not known, some studies have shown
that initial inflation pressures used to establish func-
C tional residual capacity may range between 20 cm
and 40 cm H2O (10, 17–19).
Devices used to provide PPV include the self-
Figure 3-4 Methods to Evaluate Heart Rate in the De- inflating bag, the flow-inflating bag, and the T-piece
livery Room resuscitator. The key features, advantages, and dis-
advantages of each are included in Table 3-1.
A self-inflating bag does not need a compressed
gas source in order to inflate. It fills spontaneously
is not present. The first wet linen is removed, and with air after being squeezed. It has a pop-off valve,
the team continues to dry the baby with warm which makes overinflation of the lungs less likely.
linens. You alert the team that 30 seconds have The disadvantages of the self-inflating bag, however,
passed. The physician palpates the umbilical stump include the following:
pulse and taps out the heart rate on the bed with
his hand. The heart rate is 80 bpm. The team • Inability to determine if there is a good seal on
agrees with you that the newborn is gasping. The the patient’s face
physician asks you to provide positive-pressure • The need for a reservoir attachment to provide
ventilation. delivery of 100% fractional concentration of
inspired oxygen (FIO2)
Self-inflating Mask-and-bag system designed to deliver tidal Can deliver PPV Hard to evaluate seal
bag volumes during rescue breathing without a com- between face and
One-way valve at patient connection, to prevent pressed gas source mask
exhaled gases from entering the bag Pressure-release Mask can’t be used
Rapidly refills automatically after the bag is valve minimizes risk to deliver free-flow
squeezed (during patient exhalation) of lung overinflation oxygen
• oxygen tubing and reservoir system to ensure and barotrauma Requires a PEEP
reliable FIO2 delivery when compressed gas is valve to deliver PEEP
used or CPAP
• PIP controlled by how hard bag is squeezed
2831_Ch03_045-064 13/03/14 3:16 PM Page 55
Flow-inflating Compliant bag that remains deflated until seal is Reliable FIO2 delivery Requires gas source
bag made around mask Can deliver free-flow to inflate bag
Flow-control valve regulates how much gas oxygen through mask Requires a tight seal
enters bag, how much enters mask, and how Compliance of lungs between face and
much is vented from system. can be “felt” when mask to inflate bag
PIP controlled by flow rate, flow-control valve, squeezing bag May not have pres-
and how hard the bag is squeezed sure-relief valve
Pressure manometer attached to monitor PIP
T-piece Compressed gas connected to resuscitation device Consistent PIP Requires gas source
resuscitator PIP and PEEP preset using adjustable controls Reliable FIO2 delivery to inflate lungs
on resuscitator device Unable to “feel” com-
Breath delivered by occluding expiratory opening pliance of lungs
on T-piece device at patient connection; released Pressures set before
during exhalation beginning PPV
Pressure manometer on device to monitor PIP
and PEEP
• Inability to provide 100% FIO2 free-flow oxy- When providing PPV, an RT must ensure that the
gen dependably appropriate-sized mask is being used with a close seal
around the newborn’s mouth and nose (Fig. 3-5). In
The flow-inflating bag fills up with oxygen only
cases in which a tight seal is difficult to obtain, two
when a compressed source of oxygen is attached, and
NRP providers may need to deliver manual breaths;
it requires having a tight seal between the mask and
one provider holds the mask in place using a two-
the patient to remain inflated. The advantages of a
handed technique as the other squeezes the bag to
flow-inflating bag (also known as the anesthesia bag)
over a self-inflating bag include the following:
• Ease of determining if there is a seal on the
patient’s face
• Ability to feel the compliance of the lungs
when squeezing the bag
• Ability to provide free-flow oxygen
A disadvantage of the flow-inflating bag, however,
is that in addition to requiring the presence of a gas
source, it usually does not have a pop-off valve. When
preparing to use the flow-inflating bag, an RT must
ensure that adequate flow (usually 5 to 10 L/min) is Correct
being provided to inflate the bag between manual Covers mouth and nose without
breaths and that a 5 cm H2O pressure is being deliv- extending past chin or into eyes.
ered between bagged breaths.
The T-piece resuscitator is a mechanical device de-
signed to deliver manual breaths at a set flow that
provides consistent peak inspiratory pressure (PIP)
and peak end expiratory pressure (PEEP). Similar to
the flow-inflating bag, it requires a tight seal between
the mask and the patient’s face so that it will work
well. Disadvantages of the T-piece resuscitator in-
clude the following:
• Having to preset PIP and PEEP prior to its use
Too large Too small
• Inability to change PIP and PEEP easily during Extends into eyes and Does not completely cover
resuscitation over chin. nose and mouth.
• Need for a gas source to operate the device Figure 3-5 Appropriate Technique for Mask Ventilation
2831_Ch03_045-064 13/03/14 3:16 PM Page 56
Post-Resuscitation Care
■ ■ After she receives PPV for 60 seconds, BG
Zacharian begins breathing spontaneously. You stop
providing PPV, and at 2 minutes of postnatal life, you
note that the oxygen saturation is 86% on room air
(RA). You also notice that the newborn is jittery on
physical examination. Given the mother’s prenatal
history of gestational diabetes, the physician decides
A to bring the newborn to the NICU for further man-
agement and care. You are asked to prepare the
infant transport vehicle for the patient’s transfer to a
higher level of care.
Table 3-2 Goal Oxygen Saturation Values Techniques used to provide free-flow oxygen in the
After Delivery (interquartile range delivery room are shown in Figure 3-8.
of preductal saturations) The pulse oximeter probe should be placed on the
right upper extremity of the newborn so that it re-
Time After Birth SpO2 flects preductal oxygen saturations. After placing the
1 minute 60%–65% probe on the newborn, attach the probe to the pulse
2 minutes 65%–70% oximeter because this may hasten reception of a sig-
3 minutes 70%–75% nal. It is important to note that the newborn must
4 minutes 75%–80% have normal cardiac anatomy as well as adequate
5 minutes 80%–85% cardiac output and perfusion for pulse oximetry to
10 minutes 85%–95% provide an accurate measurement.
Source: Used with permission of the American Academy of Pediatrics for use Congenital Anomalies
from American Academy of Pediatrics/American Heart Association. Textbook
of Neonatal Resuscitation. 6th ed. Dallas, TX: American Academy of Pedi- Newborns with previously known congenital mal-
atrics; 2011. Copyright holder American Academy of Pediatrics, 2011. formations are typically referred to birthing centers
C
Figure 3-8 Providing Free-Flowing Oxygen in the Delivery Room
2831_Ch03_045-064 13/03/14 3:16 PM Page 59
Multiple-Choice Questions
1. During which stage of labor is the baby deliv- 6. You attend a cesarean section of a full-term baby
ered into the extrauterine world? in breech position. BB Byrd is born at 0823 and
a. First stage is handed to the neonatal resuscitation team by
b. Second stage the surgeon. He is limp and blue and does not
c. Third stage appear to be breathing. What is the initial step
d. Deceleration phase that should be completed by the team?
e. Active phase a. Dry and stimulate
2. Which of the following fetal heart tracings is a b. Evaluate heart rate
concern? c. Provide PPV
a. Late heart rate deceleration d. Provide blow-by oxygen
b. Early heart rate deceleration 7. Thirty seconds later, BB Byrd is taking a few
c. Sinusoidal heart rate pattern gasping breaths, has central cyanosis, and is
d. B and C still limp. The nurse palpates a heart rate of
e. C and D 80 bpm. What should be the team’s next step?
3. A 38-year-old mother of three is admitted a. Blow-by oxygen
to the labor and delivery unit for induction b. Initiate PPV
of labor. She is 39 1/7 weeks’ gestation and c. Continue to dry and stimulate
was diagnosed in her second trimester with d. Initiate chest compressions
preeclampsia. She had an artificial rupture 8. You have been providing PPV to a 26 weeks
of membranes 2 hours ago, which was meco- gestation infant for 30 seconds. She is now
nium-stained. The fetal heart monitor shows 2 minutes old, and the heart rate via pulse
early onset early deceleration with each con- oximeter is 55 bpm. She’s limp and making
traction. Which items are considered neonatal no respiratory effort. What should be the next
risk factors from the description above? step in resuscitation?
I. Meconium-stained amniotic fluid a. Reposition the airway
II. Preeclampsia b. Endotracheal intubation
III. Maternal age c. Continue PPV
IV. Early decelerations d. Begin chest compressions
V. Prolonged rupture of membranes 9. Which of the following prenatal diagnoses would
VI. Induction of labor be a reason to withhold resuscitation measures?
a. I, II, III, IV, VI I. Trisomy 13
b. I, II, III II. Trisomy 21
c. I, II, IV, VI III. Anencephaly
d. I, II, VI IV. 20 weeks’ gestation
4. Which of the following is not an assessment V. 27 weeks’ gestation
question that should be asked about a baby a. II, III, IV
at the time of birth? b. I, III, IV
a. Is the newborn term or preterm? c. I, II, III, IV
b. Is the newborn crying or breathing? d. I, II, IV
c. Does the newborn have good muscle tone? 10. You are called to a full-term delivery and arrive
d. Is the baby cyanotic? after the baby is born. The delivery room nurse is
5. Which of the following should be done to en- providing stimulation and blow-by oxygen to the
sure that adequate warmth is being provided baby boy. At 1 minute, an alarm sounds to sig-
to a newborn in the delivery room? nify the need to evaluate the baby. The baby boy
I. Prewarming the delivery room to 37°C is moving actively, crying and grimacing, and has
II. Prewarming the linens a bluish hue to his hands and feet, although his
III. Drying and swaddling head and trunk are pink. You palpate the heart
IV. Rubbing the newborn’s back rate and count 12 beats in 6 seconds. Assign a
V. Placing a hat on the newborn’s head 1-minute Apgar score to this infant.
a. I, II, III a. 10
b. II, III, V b. 9
c. I, II, III, V c. 8
d. III, III, IV, V d. 7
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Section Two
Chapter 4
Respiratory Distress
Syndrome
Chapter Outline Key Terms
Chapter Objectives Air-oxygen blender
Key Terms Airway resistance
Baby Girl (BG) Gibbs Analgesia
Hyaline Membrane Disease/ Assist-control (A/C) ventilation
Respiratory Distress Syndrome Continuous positive airway
Pathophysiology pressure (CPAP)
Clinical Manifestations Dead space ventilation
Management and Treatment Gentle ventilation
Course and Prognosis Grunting
Critical Thinking Questions: Heated, humidified, high-flow nasal
BG Gibbs cannula (HFNC)
Case Studies and Critical Thinking High-frequency jet ventilation
Questions (HFJV)
Case 1: Baby Boy (BB) Goldstein High-frequency oscillatory
Multiple-Choice Questions ventilation (HFOV)
References High-frequency ventilation
Hyaline membrane disease (HMD)
Hypoplasia
Intrapulmonary shunt
Incubator
Law of Laplace
Mean airway pressure (Paw)
Muscle relaxant
Noninvasive positive pressure
ventilation (NIPPV)
Optimal peak end expiratory
pressure (PEEP)
Oxygen hood
Patient-triggered ventilation
Poiseulle’s law
Pressure control ventilation
Pressure support ventilation
Respiration
Respiratory distress syndrome (RDS)
Reticulogranular
See-saw breathing pattern
65
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Chapter Objectives
After reading this chapter, you will be able to:
1. Describe the pathological and clinical characteristics of neonatal respiratory distress syndrome (RDS).
2. Discuss how the chemical composition of surfactant improves lung compliance and its role in RDS.
3. List the changes to delivery room resuscitation that should be implemented for a very preterm infant.
4. Select initial respiratory support for a very preterm infant suspected of having RDS.
5. Assess the pulmonary status of a patient with worsening RDS and recommend changes in respiratory
support.
6. Explain the role of surfactant replacement therapy in improving pulmonary function during RDS.
7. Determine when it is appropriate to initiate noninvasive versus invasive positive-pressure ventilation.
8. Describe the rationale for using synchronized and volume-targeted ventilation for patients with RDS.
9. Evaluate blood gas results for a neonate with RDS who is receiving mechanical ventilation (MV) and
suggest changes to current ventilator settings.
10. Explain the benefits of high-frequency ventilation over conventional MV and recommend initial settings
for high-frequency oscillatory or high-frequency jet ventilation (HFJV).
■■ Baby Girl (BG) Gibbs American fairs and carnivals, and a permanent ex-
hibit was established at Coney Island in New York,
which charged an entrance fee for vacationers to
You are working the evening shift in a 24-bed level
view the premature babies (3).
IIIB neonatal intensive care unit (NICU). You are noti-
In 1898, Couney’s incubator was used at the
fied of a 25 2/7 weeks’ gestation (wG) infant that is
Chicago Lying-In Hospital, and in 1914 the first unit
going to be delivered during your shift. Susan Gibbs,
for premature babies was opened by Julius Hess at the
a 32-year-old woman, was admitted to the labor
Sarah Morris Hospital in Chicago. It incorporated
and delivery unit 4 days ago in premature labor. The
incubators to regulate temperature, supplemental oxy-
neonatologist and NICU RN ask you to come with
gen, and special feeding techniques to improve sur-
them to prepare the delivery room. You give a hand-
vival of newborns several weeks premature. Infant
off of your patients to your coworker and go to the
mortality dropped significantly, partly as a result of
delivery room to prepare for the baby’s arrival.
the improved medical care given to newborns. In the
1940s, doctors began to see a pattern of breathing dif-
ficulties in tinier, more premature babies, as they
I
n the United States in 2011, 1 in 8 babies (about would struggle and gasp for breath, expending all their
13%) were born prematurely. This rate has been energy. They would eventually tire, stop breathing,
on the rise, with a 6% increase from previous and die. In the 1960s, the first trials of mechanical ven-
years (1). As many as 49% of NICU admissions are tilation (MV) began to help these premature babies
for prematurity and thus constitute a large portion who had the characteristic “respiratory distress syn-
of the intensive care population (1, 2). Care for pre- drome.” In 1963, First Lady Jacqueline Kennedy gave
mature infants first began in the 1880s in France, birth to a premature baby boy. He was given high con-
with the invention of an incubator to care for sick centrations of oxygen that were not successful, and he
premature infants. It was designed by Alexandre died within hours of birth. This highly publicized pre-
Lion to keep the babies warm, similar to devices mature death highlighted the need for more research
used to keep eggs warm until they hatched. In 1896, for diseases of premature babies. Concurrently, in the
Martin Couney displayed actual premature babies mid-1960s, the March of Dimes changed its focus
at the Berlin World’s Fair. It was a very popular at- from polio to premature births, paving the way for
traction, but audiences didn’t know what to make rapid and significant advances in neonatal medicine
of it; at that time, society saw infant mortality as in- and improved survivability of premature babies (3).
evitable, and no resources were being put into pedi- For nearly 40% of premature births, the cause
atric medicine. The incubators became popular at is unknown; however, researchers have made some
2831_Ch04_065-110 13/03/14 3:14 PM Page 67
Box 4-1 Categories of Prematurity (1, 10) in the 1980s and 1990s, the incidence of RDS and
mortality has diminished significantly. Its incidence
• Late preterm: 34 0/7 to 36 6/7 wG for infants less than 30 wG is 60%, but it decreases
• Moderate preterm: 32 to 36 wG to 35% when corticosteroids are administered to
• Very (extremely) preterm: less than 32 wG the mother prior to delivery (13). Mortality dropped
14-fold between 1970 and 2007 (15), despite an
A Normal anatomy
B
Trachea Pulmonary
Pulmonary
capillary
capillary
Right main
bronchus
Alveolus
Left main Alveolus
bronchus Surfactant
Alveolar Alveolar CO2
sac CO2 sac
Lung O2 O2
Alveolar Alveolar
capillary capillary
membrane membrane
Figure 4-1 Characteristics of Respiratory Distress Syndrome (RDS)
2831_Ch04_065-110 13/03/14 3:14 PM Page 69
Box 4-2 Risk Factors for Developing RDS chest wall and decreased intrathoracic pressure. The
(13,14) end result is a very-low-compliance lung with normal
airway resistance and poor maintenance of FRC.
• Gestational age less than 37 weeks When RDS was first being characterized in the
• Maternal diabetes early 20th century, it was known as HMD because
• Multiple births of a unique lining, known as the hyaline membrane,
• Second twin found in the airway of these newborns upon post-
• Cesarean section with no prior labor mortem examination. The hyaline membrane was
• Perinatal asphyxia characterized as an “eosinophilic layer of structure-
• Infants whose mothers have previously had less, homogeneous material” in the bronchioles,
RDS alveolar ducts, and alveoli (20). The lungs were also
• Male sex abnormal, described in the 1950s as having the fol-
• Chorioamnionitis lowing characteristics:
• Hydrops fetalis • Dull red instead of pink
• Consistency of liver
• Congested and edematous
• Little evidence of aeration
• Engorged alveolar capillaries
increase in preterm birth rates. The severity of the
• Most of the parenchyma collapsed
disease has also been restricted to the very preterm
• Overdistended alveolar ducts and respiratory
and ELBW babies, with an incidence as high as 74%
bronchioles
for infants 501 g to 1,000 g (16, 17).
RDS does not, however, affect sex and races With the advent of advanced respiratory tech-
equally. It affects males more often than females, nologies such as CPAP, exogenous surfactant, and
though the exact physiological cause is not yet un- prenatal corticosteroid delivery, developed countries
derstood. In one study, the incidence of RDS was no longer see the pathological hyaline membranes.
more than three times higher in boys than in girls, However, it is important to remember this resulting
and this is particularly noticeable at later gestational pathology because it reflects lung characteristics
ages and at heavier weights (18). Black fetuses de- without necessary interventions.
velop surfactant more rapidly than do white fetuses
and thus historically have had a lower incidence of Surfactant Deficiency
RDS (19). Surfactant is a chemically complex agent whose
Patients with RDS require extensive care from RTs, main function is to stabilize the air-liquid interface
focusing on early establishment of functional residual of the alveoli and bronchioles and to lower surface
capacity (FRC) using continuous positive airway tension. Lower alveolar surface tension improves
pressure (CPAP), early surfactant delivery, appropri- lung compliance, thereby decreasing work of breath-
ate ventilatory support with avoidance of volutrauma ing (WOB). Surfactant molecules are made and ex-
or atelectrauma, oxygen delivery to maintain ade- creted by alveolar type II cells, which appear in fetal
quate partial pressure of oxygen (PaO2), and discon- development during the canalicular phase (gestation
tinuation of respiratory support as soon as possible weeks 17 to 26). Surfactant serves to ease the alve-
to avoid long-term complications. Close monitoring oli’s ability to stretch during inspiration and pre-
and assessment, frequent changes in respiratory set- vents alveolar collapse and eventual atelectasis
tings or modalities, and careful attention to changes during exhalation or compression of the alveoli.
in clinical presentation all contribute to improved Mature pulmonary surfactant is made of 90%
outcomes for premature infants with RDS. lipids (mostly phospholipids) and 10% glycoproteins
(Fig. 4-2).
Pathophysiology There are many types of lipids, but surfactant is
The primary cause of respiratory distress is under- made mostly of phospholipids. They serve to interact
development of the lung. The biggest causative factor with air in the alveolar space, helping to reduce the
is surfactant deficiency, but it is compounded by surface tension of the lungs upon compression or ex-
other problems that result from lung hypoplasia, in- halation. The main phospholipids in the surfactant
cluding decreased surface area for gas exchange, thick are phosphatidylcholine (PC), which makes up about
alveolar-capillary (A-C) membrane, and underdevel- 80% of lipids, and phosphatidylglycerol (PG), which
oped (and thus insufficient) vascularization. Neonates makes up between 8% and 15% of the lipids (21, 22).
with RDS also have an increased likelihood for pul- Immature surfactant, found in the alveoli beginning
monary edema. The mechanics of the thoracic cavity at approximately 24 wG, lacks PG, and therefore is
also cause problems, such as an overly compliant less structurally stable and is inhibited by hypoxia,
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Surfactant Alveolar
Alveolar layer type I cell
Surfactant
layer type I cell
Alveolar
Alveolar fluid
fluid Alveolar
macrophage
Alveolar Alveolar
type II cell macrophage
Alveolar
Exhalation type II cell
Inspiration
Figure 4-2 Chemical Composition of Surfactant
hyperthermia, and acidosis. Neonates born between is the most commonly occurring type of PC phos-
24 wG and 35 wG are very susceptible to surfactant pholipid, comprising about 50% of the PC phospho-
deficiency, causing high surface tension and leading lipids. Both proteins enhance surface activity, in
to increased WOB, respiratory distress, atelectasis, particular initial film formation and re-extension,
and pulmonary injury. PG appears at about 35 wG which are important for proper dynamic behavior
during the saccular phase of lung growth, and sur- during the breathing cycle. Patients without these
factant is then much more stable. components are more susceptible to atelectasis,
There are four surfactant proteins (SP)—A, B, C, pneumonia, volutrauma from MV, and death.
and D—found in surfactant. They are mainly in-
Lung Hypoplasia
volved in promoting adsorption and the stabilization
and respreading of surface film to decrease surface The gestational age of a newborn at birth signifi-
tension. Proteins make up about 6% to 8% of the cantly impacts how developed the lungs are and the
total weight of surfactant (23). potential for respiratory distress. Each stage of fetal
pulmonary development is discussed in detail in
• Surfactant proteins SP-A and SP-D are round, Chapter 2. About 23 wG is the current agreed limit
hydrophilic, and interface with the fluid por- of viability (7), and a description of lung develop-
tion of the alveolar membrane. Protein A is ment after this stage is warranted to understand the
the major protein in surfactant, but both are potential for respiratory dysfunction:
associated with the body’s host defense mecha-
nisms; assist in clearing bronchioles and alve- • 24 to 28 wG: Division of intrasegmental air-
oli of inhaled pollution; and bind to pathogens ways is fastest between weeks 10 and 24, by
such as bacteria, viruses, and fungi to assist which time about 70% of the airway genera-
with phagocytosis. These proteins also help tions present at birth have formed (25). Gas ex-
prevent fluid from entering the alveolar space change isn’t possible until the capillary network
and help maintain the sterile conditions of the and alveoli have a sufficient surface area and
respiratory surface. Without these proteins, the
lungs are highly susceptible to infection and
pulmonary edema. Box 4-3 Agents Inhibiting Surfactant
• Surfactant proteins SP-B and SP-C are very Function (24)
small hydrophobic proteins that are found in
much smaller numbers in surfactant, but they • Cholesterol
play critical roles in the formation and stabi- • Bilirubin
lization of pulmonary surfactant films. • Amniotic fluid
• Meconium
Surfactant is sensitive and is susceptible to inac- • Elastin
tivation by foreign bodies or changes in the content • Fibrin monomers
of the air-alveolar capillary interface. Box 4-3 lists • Immunoglobulins
the agents that can cause surfactant inactivation or • Hemoglobin
dysfunction. Researchers have found that the most • RBC membrane lipids
critical components for functional surfactant are • Plasma/serum
the phospholipid DPPC (dipalmitoylphosphatidyl- • Albumin
choline) and proteins SP-B and SP-C (23). DPPC
2831_Ch04_065-110 13/03/14 3:14 PM Page 71
Chest
movement
Intercostal
retraction
Xiphoid
retractions
Nares
dilation
Expiratory
grunts
RDS was first studied and treated with oxygen in the plan to reduce the incidence of preterm birth would
1950s, survival rates for the disease have improved, require first identifying which pregnant mothers are
and its prevention has been particularly successful. at high risk of delivering prematurely, then prevent-
Treatment begins from the moment labor starts until ing preterm labor for these mothers, and if that fails,
discharge from the NICU and focuses on surfactant providing pharmacological therapies to increase lung
replacement, establishing FRC, and supporting ven- maturation prior to delivery.
tilation and oxygenation as necessary. The ability to identify women whose pregnancies
are at higher-than-average risk of preterm birth
Prevention of RDS would allow clinicians to provide these women with
The single best way to prevent RDS is to prevent a higher level of antenatal care, with the aim of pre-
preterm delivery. Preterm birth is a major public venting the preterm birth. Even though it is relatively
health problem worldwide, occurring in 6% to 10% easy to look retrospectively for common factors in
of births in developed countries (33). The proportion women who delivered prematurely, there is not yet a
of pregnancies that end prematurely, between 20 and useful and consistent scoring system to identify a
36 weeks, has not fallen in recent years. A successful woman at high risk for a preterm delivery. The risk
2831_Ch04_065-110 13/03/14 3:14 PM Page 74
Table 4-1 Factors in Premature Infants That Can Increase Severity of Respiratory Distress (14)
Clinical Symptom Cause in Premature Infants How It Contributes to Worsened Respiratory Distress
ready. Infants less than 29 wG should be imme- provide alveolar stability and increase FRC
diately placed in a reclosable food-grade poly- for babies with a surfactant deficiency. In the
ethylene bag rather than dried with towels delivery room, this is achieved by using a
because they are more susceptible to the effects mask or nasal prongs connected to a flow-
of evaporative heat loss (50). A transport incu- inflating resuscitation bag or a T-piece resus-
bator should be used to maintain the newborn’s citator held tightly to the baby’s face or nose.
temperature during the move to the nursery A self-inflating bag cannot be used to deliver
after resuscitation. noninvasive CPAP. A CPAP setting of 4 to
• An air-oxygen blender and pulse oximeter 6 cm H2O is a safe and adequate amount of
should be available for all preterm births. pressure in the delivery room until additional
There is a large body of evidence showing information about lung function is available.
that blood oxygen levels in uncompromised Several studies have shown that using CPAP
babies generally do not reach extrauterine in the delivery room for extremely premature
values until approximately 10 minutes after infants, rather than prophylactic intubation
birth. Oxyhemoglobin saturation may nor- and MV, can reduce the length of time on
mally remain in the 70% to 80% range for sev- MV and decrease the incidence of lung injury.
eral minutes following birth, thus resulting in • Positive-pressure ventilation (PPV) will be
the appearance of cyanosis during that time. needed if spontaneous respiration and CPAP
Other studies have shown that clinical assess- can’t provide adequate oxygenation. Use the
ment of skin color is a very poor indicator of lowest inflation pressure necessary to achieve
oxyhemoglobin saturation during the immedi- a positive response (HR greater than 100 bpm
ate neonatal period and that lack of cyanosis and improving SpO2). Generally speaking,
appears to be a very poor indicator of the 20 to 25 cm H2O is an adequate peak airway
state of oxygenation of uncompromised pressure for a premature infant, but clinicians
babies following birth (51). Until more infor- may need to increase the pressure cautiously
mation is available on appropriate saturation if improvement is not observed.
levels for preterm infants immediately after • If intubated, provide positive end expiratory
birth, clinicians should continue to follow the pressure (PEEP) at 2 to 5 cm H2O.
recommended SpO2 levels for term babies, as • Consider giving surfactant in the delivery
described in Chapter 3 and listed in Table 4-2. room if the baby is significantly premature
Pulse oximetry and use of an air-oxygen (less than 30 wG). Studies have shown that
blender to more accurately treat hypoxemia earlier delivery of surfactant is better, even
are particularly critical for infants born less if a baby is exhibiting no signs of respiratory
than 32 wG. distress (52, 53). However, indications for
• After birth, if a preterm baby is breathing and timing of surfactant administration
spontaneously and has a heart rate (HR) remain controversial (49).
greater than 100 bpm, allow the baby to • Prior to 32 wG, a portion of the brain called
progress through the first few minutes of life the germinal matrix has within it a fragile net-
without additional assistance. Consider the work of capillaries that are prone to rupture
following interventions: and bleeding (see Chapter 8 for more informa-
• Provide CPAP if respirations and HR are ad- tion). Physiological events that can cause rup-
equate, but the baby still has labored respira- ture include rapid changes in PaCO2, blood
tions, cyanosis, or a low SpO2. CPAP will pressure, or blood volume. Inadequate blood
flow to the brain can cause damage to its
white matter, resulting in cerebral palsy. Meas-
ures that can be taken in the delivery room to
Table 4-2 Pulse Oximetry Level Recommenda- minimize the risk of this type of brain injury
tions Based on Age in Minutes (49) include the following:
• Handling the baby gently
Time After Birth SpO2 • Avoiding Trendelenburg (head down)
1 minute 60% to 65% placement
2 minutes 65% to 70% • Avoiding delivering excessive positive pressure
3 minutes 70% to 75% during manual ventilation or CPAP
4 minutes 75% to 80% • Using pulse oximetry and blood gas values
5 minutes 80% to 85% when available to adjust ventilation and
10 minutes 85% to 95% oxygenation gradually and appropriately
• Avoiding rapid infusions of fluid
2831_Ch04_065-110 13/03/14 3:14 PM Page 77
■ ■ On the way to the delivery room, the neonatologist instillation of surfactant in the delivery room,
briefs you on the information she has regarding within minutes of birth. This early treatment
Susan’s pregnancy. She has no fever or signs of should help prevent iatrogenic lung injury
infection and no significant bleeding or placental and improve oxygenation and ventilation.
abnormalities. Initial treatment with terbutaline was Prophylactic therapy has been shown to de-
successful at stopping contractions, and she has crease the need for MV and lower the inci-
received three doses of corticosteroids. The father dence of air leak syndromes, BPD, and death
of the baby was deployed for active military duty (52, 53, 55, 56). The definition of “high risk”
2 weeks ago, and she has admitted to having a hard is not standardized, but the American Associ-
time coping since his departure. The neonatologist ation for Respiratory Care (AARC) clinical
discussed the potential outcomes for delivery of practice guidelines suggest using a gestational
Susan’s daughter at this early stage in development. age of less than 32 weeks or a birth weight
She acknowledges the potential poor outcomes less than 1,300 g (57).
and would like to have a full resuscitation provided • Rescue: Also described as “selective” surfac-
at delivery. If new information arises in the delivery tant replacement therapy, rescue surfactant
room, she would like the neonatologist to share that replacement involves waiting to deliver sur-
information with her so she can adjust the care plan factant until evidence of RDS is seen. Evi-
if necessary. The neonatologist recommends that dence includes a chest radiograph with
Susan bring in a family member or close friend as characteristic RDS features, increased WOB,
support for her, and she agrees to have her sister or increased oxygen requirements. Though
with her at the delivery. Contractions began again studies in the early 2000s showed an improve-
12 hours ago, and Susan progressed to full cervical ment in patient mortality and morbidity with
dilation. Her rupture of membranes was 5 hours ago, prophylactic therapy, the use of early CPAP
and there are no confounding factors to indicate it combined with rescue therapy results in equal
will be a stressful delivery course. You and the team improvement in outcomes, and its use may
prepare the room: You increase the temperature of be increasing (Evidence in Practice 4-1). The
the delivery room, preheat the radiant warmer, and benefit of rescue therapy includes less time
place a polyethylene bag at the foot of the mattress. on MV, the potential to avoid intubation for
You set up the T-piece resuscitator and turn the some patients, and a reduction in costs as a
fractional concentration of inspired oxygen (FIO2) on result of providing therapy only to those
the air-oxygen blender to 0.21. Your hospital’s proto- patients who require it.
col is to administer surfactant in the delivery room
for all infants born less than 26 wG, so you warm the
surfactant to body temperature and place it in the ● Evidence in Practice 4-1
warmer in preparation for delivery.
Surfactant Versus CPAP in the Delivery
Room (58)
Surfactant Replacement Therapy Research in the 2000s clearly showed an improvement
in neonatal outcomes when intubation and early use of
One of the biggest successes in the treatment
surfactant occur in the delivery room. In the late 2000s,
of RDS was the U.S. Food and Drug Administra-
research on the use of nasal continuous positive airway
tion (FDA) approval of the first formulas for surfac-
pressure (NCPAP) in the delivery room (with or without
tant-replacement therapy in 1991 (54). Surfactant
surfactant therapy) has shown patient outcomes simi-
replacement therapy involves the instillation of
lar to those of prophylactic surfactant therapy. Results
artificially derived surfactant directly into the lungs.
of the patient-management strategy of early NCPAP
Surfactant administration early in the course of
and rescue surfactant appears to be equal to prophy-
RDS can rapidly improve lung compliance, FRC,
lactic surfactant treatment. More research is ongoing
and VT and prevent lung injury that is otherwise
to determine exactly which management strategy of-
characteristic of surfactant-deficient lungs.
fers the best lung protection, lowest morbidity, and
The timing of surfactant replacement therapy has
lowest incidence of BPD:
been a topic of much debate and research. In gen-
eral, there are two main strategies for initiation of • Prophylactic surfactant therapy in the delivery
surfactant replacement: room
• Prophylactic surfactant therapy, then extubation
• Prophylactic: This form of therapy occurs to NCPAP
as soon as possible in a newborn at high risk • NCPAP and rescue surfactant therapy
for developing RDS. Frequently, this involves
2831_Ch04_065-110 13/03/14 3:14 PM Page 78
There are two types of exogenous surfactant The technique for surfactant delivery is designed
(surfactant that originates outside the lungs). One is to promote even distribution of surfactant within
natural surfactant, which is obtained from animal the lungs and is usually based on manufacturer
lungs, usually bovine or porcine. Natural surfactant recommendations. The dose is normally broken into
can be obtained from pulverized lung or from a lung two or four equal parts known as aliquots, and each
lavage. Pulverizing the lung has the potential for de- is delivered to a lung region—left (left upper lobe,
stroying some of the surfactant proteins A, B, C, and left lower lobe) and right (right upper and middle
D, which makes it less capable of protecting the alve- lobes, right lower lobe)—with a short break between
oli from infection or fluid entry when compared with aliquot delivery to ensure instillation into the alve-
native surfactant. Lung lavage is a more gentle extrac- oli. The patient is also positioned to promote equal
tion technique, leaving more of these proteins intact distribution throughout the lungs:
to perform effectively at the A-C membrane. Surfac-
• Head up, right side-lying
tant can also be made synthetically and will have the
• Head up, left side-lying
physiological properties of surfactant without the
• Head slightly down, left side-lying
proteins. The dosage for exogenous surfactant is man-
• Head slightly down, right side-lying
ufacturer dependent and is described in Table 4-3.
Equipment necessary for surfactant replacement The neonate should be suctioned prior to instilla-
therapy includes (57) the following: tion of exogenous surfactant to clear the airway. The
feeding tube or catheter is connected on one end to
• A 5- to 10-mL syringe containing the entire
the full surfactant dose. The patient is positioned for
surfactant dose, warmed to room temperature
the first dose, and the catheter is advanced into the
• A catheter for delivery of surfactant, which can
endotracheal tube (ETT) using sterile technique until
be either a sterile 5 French (Fr) size feeding
the tip is flush with the end of the ETT. The first
tube or a specially designed catheter for surfac-
aliquot is delivered, and the catheter is removed from
tant delivery
the airway. PPV is initiated via resuscitation bag
• A resuscitation bag
or mechanical ventilator to aid passage into the alve-
• Suctioning equipment
oli and prevent occlusion of the ETT or large air-
• Intubation supplies, if the patient does not
ways with surfactant. PPV is continued for at least
already have an endotracheal tube
1 minute or until the patient is stable and not experi-
Additional supplies standard to neonatal respi- encing bradycardia or hypoxemia, which would sug-
ratory care that should be available include a venti- gest airway occlusion. This procedure is repeated for
lator that can measure delivered or exhaled VT and the remaining aliquots. The RT must stay near the
inspiratory pressure, a blended gas source, electro- patient to ensure that excessive VT delivery does not
cardiogram (ECG) monitor, pulse oximeter, CO2 occur after surfactant replacement therapy and will
monitor, radiant warmer or incubator, and resusci- need to wean the ventilator settings if it appears that
tation equipment. lung overdistention is occurring. Suctioning of the
Nasal cannula • Provides tactile stimulation while • FIO2 varies with changes in 0.21–0.70 at flows
delivering oxygen inspiratory flow and VT of 0.25–2 LPM
• Can feed and care for patient with- • Cannula prongs can become
out interrupting oxygen delivery occluded by secretions
• Allows patient greater mobility
High-flow nasal • Delivers accurate FIO2 at higher • Incorrect cannula size can 0.21–1, at flows of
cannula flows (>6.0 LPM) provide inadvertent positive 1–8 LPM
• Keeps patient comfortable distending pressure, similar
• Delivers gas at body temperature, to CPAP
100% relative humidity
Face mask • Can provide moderate concentra- • FIO2 can vary significantly 0.35–0.50 (FIO2 data
tions of oxygen • Must be removed for feeding from studies in chil-
• Provides oxygen to nose and • Can cause skin irritation dren and adults) at
mouth flows of 5–10 LPM
Oxygen hood • Maintains a relatively constant FIO2 • Higher FIO2 may be found at 0.21–1
• Does not need to be attached to bottom of hood
patient’s skin • High noise levels inside
• Must be set at 5–10 LPM to
flush out exhaled CO2
• Baby unable to be held or
nursed when hood in place
Incubator • Requires no additional device to • When care ports are open, 0.21–0.65
(environmental attach to patient FIO2 may vary widely
delivery system) • Displays set and measure FIO2
continuously on new model
incubators
2831_Ch04_065-110 13/03/14 3:14 PM Page 82
These devices use microporous tape that adheres to used as an alternative to oxygen hoods when use of
the face and a clear tab with an adhesive backing that the latter is not possible, such as for transport or
will secure the cannula to the tape. when the infant is being swaddled and held by a
family member.
• In 2000, the first heated, humidified, high-flow
An oxygen hood or “oxyhood” is a clear plastic en-
nasal cannula (HFNC) was approved for use
closure that is placed around a neonate’s head and
in the United States by the FDA (70). HFNC
connected to a humidified gas source to provide a
produces a high flow of highly humidified air,
fixed oxygen concentration. An oxygen hood is an
virtually free of droplets, at body temperature
ideal method of oxygen delivery for neonates who re-
or above. This high humidity allows for much
quire higher FIO2 but do not have additional respi-
higher flow rates (1 to 8 liters per minute
ratory support requirements. At gas flows of greater
[LPM]) to be tolerated by neonatal patients
than 7 LPM, FIO2 delivered via an oxygen hood can
without the risk of nasal mucosal drying or
be maintained at 0.21 to 1. Gas flow must be main-
bleeding. HFNC has been suggested as a high-
tained above 5 LPM to ensure that exhaled CO2 is
flow (fixed-performance) oxygen-delivery de-
flushed out of the hood. The gas in the hood should
vice because, when set to higher flows, it can
be measured intermittently to ensure accurate FIO2
meet or exceed inspiratory demand. It can also
delivery to the patient, and an air-oxygen blender or
flush carbon dioxide from the nasopharyngeal
air-entrainment device should be used to select and
anatomical dead space, which creates a reser-
adjust the desired FIO2. The sound within an oxy-
voir of fresh gas for early inspiration, improv-
hood can be loud, and neonates can’t be fed or held
ing the accuracy of delivered FIO2. Several
during its use.
HFNC devices are now available for neonatal
Incubators provide large volumes of oxygen-
use and vary in their design and setup, but all
enriched gas to the atmosphere immediately surround-
have a traditional patient-cannula interface
ing the patient. Incubators are used in the neonatal
connected to a humidifier and air-oxygen deliv-
population to provide variable control of environmen-
ery system, which will regulate gas flow, tem-
tal temperature and humidity. They minimize heat loss
perature, percent relative humidity, and set
through conduction and can promote a quiet, dark en-
FIO2. Data from NICUs suggest that patients
vironment, which minimizes external stimuli that can
are more comfortable using HFNC than any
be distressing to premature infants. Supplemental oxy-
other high-flow oxygen-delivery device (71)
gen can be provided by connecting an oxygen source
(oxygen hood, mask, nasal CPAP, or MV). Sev-
and heated humidifier directly to the incubator and
eral studies have suggested that the higher flows
using the incubator’s control panel to set an FIO2. Set
from NCs can increase esophageal and pharyn-
oxygen values can range from 0.21 to 0.65 on most in-
geal pressures in neonates, providing a distend-
cubator models, but the actual oxygen concentration
ing pressure similar to CPAP (72–74). To avoid
delivered to the patient can vary widely because of the
inadvertent positive airway pressure during
frequent entry of room air when the hand ports are
HFNC delivery, nasal prongs should be se-
opened for patient assessment and nursing care. New
lected that do not significantly occlude the
incubators have an FIO2 analyzer built in that will con-
nares (73, 75, 76).
tinuously display the set and delivered oxygen concen-
Oxygen masks are cone-shaped devices that fit tration within the incubator. If this is not available, the
over the patient’s nose and mouth and are held in air inside the incubator should be measured intermit-
place with an elastic band that fits around the pa- tently to ensure accuracy of delivered FIO2.
tient’s head. Oxygen is delivered through small-bore
tubing connected to the base of the mask. During Noninvasive Respiratory Support
inspiration, the patient draws gas from the oxygen
CPAP has been used noninvasively in the neona-
flowing into the mask and from room air through
tal population for over 40 years as a less-invasive form
ports on the sides of the mask. Oxygen flow rates
of pulmonary support. CPAP is the application of
into the mask must be sufficient to wash out exhaled
positive pressure to the airways of the spontaneously
carbon dioxide that can accumulate in the mask. De-
breathing patient, via nasal prongs or a mask, through-
livered FIO2 values by mask have not been studied
out the respiratory cycle. It provides a positive pressure
in infants or neonates, but in children and adults they
that increases FRC and offers the following benefits:
can range from 0.35 to 0.50. Delivered FIO2 varies
based on the flow of oxygen to the mask, the size of • Alveolar and airway stabilization
mask, and the patient’s breathing pattern. The mask • Decreased airway resistance
must be removed for feeding or nursing, may be • Improved ventilation-perfusion matching, clini-
restrictive, and can cause skin irritation where it cally exhibited as improvements in oxygenation
touches the skin. In the NICU, masks are frequently and ventilation
2831_Ch04_065-110 13/03/14 3:14 PM Page 83
• Nasal interface, consisting of a set of bi-nasal patient comfort and stabilizes lung function in in-
prongs or a nasal mask, held in place using a fants with weak respiratory efforts and leaky nasal
bonnet with a securing device such as Velcro, interfaces. Gas is regulated with a flow driver, which
safety pins, or ties (Fig. 4-6) regulates flow to the patient or out through an exha-
• Patient circuit lation tube (Infant Flow) or into a low-pressure area
• Pressure-generation apparatus (86) (ARABELLA). When the machine senses the back
pressure from the patient interface, it diverts gas
There are three major types of NCPAP delivery
away from the nares, making it easier for the patient
devices for the neonatal population: ventilator CPAP
to exhale. The net effect of these systems is the pre-
(also known as continuous-flow CPAP), variable-
vention of excess CPAP pressures by venting unnec-
flow CPAP, and bubble CPAP. A description of each
essary gas away from the patient. These systems
is found next (Table 4-6).
require their own pressure generator, equipment cir-
Ventilator CPAP cuit, and patient interface. Variable-flow systems
have been shown to provide adequate CPAPs and
The most simple and efficient system, often referred have lower oxygen requirements and respiratory rates
to as “conventional CPAP,” the ventilator CPAP has (88–90) and shorter duration of CPAP support (91)
been used since the 1970s (87). It requires little addi- than do other CPAP designs.
tional setup because it uses a neonatal ventilator and
patient circuit adapted for NCPAP. A set of nasal Bubble CPAP
prongs are provided, replacing the patient Y connec- Bubble CPAP is an inexpensive, simple, and effective
tor. This setup uses the ventilator’s PEEP valve way to provide CPAP to premature infants, and its
(usually an expiratory resistor valve) to set and reg- design has been used since the 1970s. There is a lot
ulate CPAP levels and allows release of excess circuit of interest in this method of CPAP delivery, partic-
pressure. Smaller patients may find it uncomfortable ularly in resource-limited environments (Special Pop-
to exhale against the high continuous flow in this ulations 4-1). Bubble CPAP consists of the following:
circuit and thus may not show as much alleviation
in WOB or general comfort. In the most serious • Neonatal dual-limb ventilator circuit
cases, patients may experience CO2 retention as a • Humidifier connected to an air-oxygen blender,
by-product of this expiratory resistance. gas set to 4 to 10 LPM
• NCPAP prongs
Variable-Flow CPAP • Pressure manometer attached at the nasal
prong interface
The design of variable-flow CPAP systems functions
• Water column filled to 10 cm with sterile water
to provide adequate inspiratory flow, maintain stable
or a 0.25% acetic acid mixture
pressure at the nares and large airway, and thus
maintain a more consistent FRC. Variable-flow See Figure 4-6 for a schematic setup of bubble
CPAP systems are able to maintain a low level of im- CPAP. The inspiratory limb is connected to the hu-
posed WOB by minimizing the need for patients to midifier and then to the bi-nasal prongs. The ex-
exhale against incoming gas flow. This improves piratory limb is submerged in the water column;
Nasal Distal
CPAP tubing
cannula
Oxygen
blender
Thermometer
Proximal Heated
tubing humidifier
A B
Figure 4-6 NCPAP Interface (A) An example of a NCPAP patient interface.
(B) A schematic drawing of bubble CPAP.
2831_Ch04_065-110 13/03/14 3:14 PM Page 85
Ventilator • Ventilator circuit with Y • Simple and efficient Pressure monitor- • Hudson bi-
CPAP connector replaced with after extubation ing and pressure nasal prongs
nasal prongs and adapter • Requires little addi- regulation less re- • Argyle bi-
tubes, attached with a tional equipment sponsive to small nasal prongs
bonnet and connectors to run patient efforts
• Has a built-in pop-
off in case of excess
pressure buildup
Variable- • Gas flow determined by • Provides lower im- Requires its • Cardinal
flow CPAP a flow driver, with excess pedance to exhala- own generator, Health Infant
gas diverted away from tion, decreasing circuit, and pa- Flow CPAP
the patient when CPAP WOB tient interface • Hamilton
met and during exhalation ARABELLA
Bubble • Neonatal dual-limb ventila- • Simple and Delivered CPAP • N/A
CPAP tor circuit inexpensive may fluctuate
• Humidifier and blender based on water
• NCPAP prongs levels, gas flow,
• Pressure manometer and resistance in
• 10-cm water column circuit
Noninvasive • Similar to variable flow • Improving alveolar Little guidance on • SiPAP
positive CPAP, with a set rate and recruitment and how to select • NeoPAP
pressure two levels of CPAP stimulation for high CPAP set-
apnea tings, TI, or rate
C VE = VT × RR
Time In neonatal pressure ventilation, VT is most closely
Figure 4-8 Breath Delivery for A/C, SIMV, and PSV determined by PIP. In the past, several strategies of
2831_Ch04_065-110 13/03/14 3:14 PM Page 95
Table 4-8 Preferred Ventilator Setting Changes to Adjust Blood Gas Values During Neonatal
Mechanical Ventilation
Desired
Change FIO2 Conventional Ventilation HFOV HFJV
Volume (PIP/VT) Rate PEEP ΔP Hz Paw PIP Rate PEEP CMV Rate
↑ PaCO2 — ↓ ↓ —* ↓ ↑ — ↓ — — —
↓ PaCO2 — ↑ ↑ —** ↑ ↓ — ↑ ↓ —** —
↑ PaO2 ↑ — — ↑ — — ↑ — — ↑ ↑***
↓ PaO2 ↓ — — ↓ — — ↓ — — ↓ —
*Increasing PEEP will decrease ΔP, so the RT can increase PaCO2. It is not the preferred method to adjust PaCO2
unless there is also radiographic evidence of atelectasis.
**Decreasing PEEP will decrease ΔP, so the RT can decrease PaCO2. It is not the preferred method to adjust PaCO2
unless there is also radiographic evidence of alveolar hyperinflation.
***Temporarily (15 to 30 minutes), in the presence of atelectasis, in tandem with increasing PEEP
ventilation have been described that manipulate rate in the neonatal population, this equates to 30 to
and pressure relationally to maintain an appropriate 60 breaths/min. RR should be adjusted in SIMV
acid-base balance, although no one strategy has been mode only after assessing whether alveolar recruit-
proven superior for patients with RDS. Normoven- ment is adequate and that delivered VT is greater
tilation is a reasonable strategy (pH 7.35 to 7.45 and than 4 mL/kg (see Table 4-8). The rate should be in-
PaCO2 35 to 45 mm Hg), but the risks associated creased in A/C if the patient is not making sponta-
with hypocarbia in neonates is significant, causing neous respiratory effort above the minimum set
an increase in the risk of IVH and BPD with recur- ventilator rate. If a patient is consistently triggering
rent PaCO2 of less than 30 mm Hg (129, 130). There additional ventilator breaths, increasing the rate will
is also some evidence that hypercapnia may make not result in changes to blood gas values.
VLBW infants more vulnerable to brain injury, par-
ticularly if it occurs within the first week of life (131). Pressure
Gentle ventilation was introduced in the mid-1980s Selecting an adequate but not excessive PIP is one of
as a lung-protective strategy in which a PIP is selected the most important goals for RTs during MV for
that provides adequate air entry and an IMV rate of 20 RDS. It can be challenging to find the perfect pres-
to 40 breaths/min is initiated and adjusted to maintain sure, but by assessing the patient, it should be clear
a PaCO2 of 40 to 60 mm Hg (132). This type of venti- whether the chosen PIP is appropriate. Clinicians
lation, also described as “permissive hypercapnia,” is should continually evaluate exhaled VT, cardiac out-
a method in which slightly higher PaCO2 or pCO2s put, pressure and volume measurements, and blood
values are acceptable, in deference to avoiding or gas values to verify PIP selection. The lowest PIP
preventing lung injury. Initial publication of the gentle that adequately ventilates the patient is the most ap-
ventilation strategy occurred before synchronized ven- propriate and is seen by the following:
tilation or VT monitoring capabilities, and therefore
the published method of selecting ventilator settings is • Exhaled VT greater than 3 mL/kg and less than
not consistent with current practice. It is, however, a fre- 8 mL/kg
quently used method for patients with RDS. • pH 7.25 to 7.35 with PaCO2 45 to 55 mm Hg
Prior to having the ability to measure VT delivered
Rate and Inspiration Time during TCPL ventilation, clinicians would select ven-
Normal neonatal respiratory rate is 40 to 60 breaths/ tilator PIP based on visible chest rise and equal bi-
min, and normal I/E ratio (ratio of the duration of lateral breath sounds. This practice is inexact and
inspiration to the duration of expiration) in sponta- may lead to the selection of excessive pressures.
neously breathing neonates is 1:3 to 1:4 (27). The It should be used only if other methods of patient
characteristics of RDS indicate that most patients assessment are not available.
have a low lung compliance and normal airway re-
sistance. This means that inspiratory times will be Volume
relatively short, around 0.25 to 0.40 seconds. Volumes for neonatal ventilation have been described
As with adult ventilation, ventilation for RDS can differently in different studies and based on the specific
begin by supporting the majority of patient RR; modes used. The goals have ranged from 4 to 8 mL/kg,
2831_Ch04_065-110 13/03/14 3:14 PM Page 96
with most targeting around 4 to 6 mL/kg (102, 123, bradycardia, hypoxemia (SpO2 less than 85%), or an
133, 134). Lower VT values (less than 4 mL/kg) may increase in FIO2, then the patient is considered to
increase spontaneous ventilation but may also increase be ready for extubation (137, 138). A patient can be
CO2, lung inflammation, and WOB (128, 135). considered to be on minimal ventilator settings
Increases in ventilator settings may be necessary when he or she is achieving normoventilation on the
if oxygenation and ventilation fall outside the target following:
range. When adjusting ventilator settings to de-
• FIO2 less than 0.40
crease PaCO2 and increase pH, PIP should be in-
• PIP 10 to 15 cm H2O
creased if the VT is less than 4 mL/kg. Caution
• Rate 10 to 20 breaths/min
should be used if increasing PIP when VT is be-
tween 4 and 7 mL/kg to avoid overstretching of the Extubation to NCPAP is a commonly used method
alveoli. If chest radiograph evidence shows atelec- of weaning in neonatal units (139), and a NCPAP
tasis or pressure volume curves indicate that alveo- level of 5 to 6 cm H2O is usually appropriate.
lar derecruitment occurs during exhalation, then Approximately 30% of intubated preterm infants
PEEP and PIP should be increased incrementally fail an extubation attempt, requiring reintubation
(i.e., each should be increased by one unit at a time) and MV. Extubation failure in ELBW infants is
to improve alveolar stability and maintain the pre- mainly caused by upper-airway instability, poor res-
vious ΔP (see Table 4-8). piratory drive, and alveolar atelectasis or derecruit-
ment (140). The rate of extubation failure using
Weaning NCPAP is similar at 25% to 40% (139).
When weaning from MV, frequent small changes are Failing Conventional Mechanical Ventilation
preferable to occasional larger changes. To increase
PaCO2, decrease PIP by 1 to 2 cm H2O (1 cm H2O if There are no standard guidelines for patients who
PaCO2 is 35 to 40 mm Hg, 2 cm H2O if less than have failed a course of conventional ventilation
30 mm Hg) wean rate when PIP is at a minimal level (CV), but failure can be considered if that patient’s
of 12 to 15 cm H2O or exhaled VT is 4 mL/kg. Rate pH cannot be consistently maintained at more than
changes in SIMV can be made at 5- or 10-breaths/min 7.20 with PaCO2 levels greater than 60 mm Hg.
increments, with special attention paid to how much Ventilation that causes a significant impedance on
respiratory support is being weaned. For instance, if cardiac output and any level of pulmonary air leaks
the current RR is set at 40 breaths/min and the pa- during MV (see Chapter 7 for more information on
tient is breathing 20 additional times above the pulmonary air leaks) should both be contributing
mandatory rate, decreasing the rate to 35 removes factors in the decision to move to high-frequency
roughly 12% of the ventilator breaths supporting the ventilation.
patient and only 8% of the total RR for the patient.
In contrast, decreasing the RR to 30 in the same pa- ■ ■ After delivery of an analgesic, you intubate BG
tient removes 25% of ventilator-sized breaths and Gibbs with a 2.5-cm ETT 7 cm at the lip, observing
17% of the total RR. Changing the RR in this patient chest rise, misting in the tube, and colorimetric
by 5 breaths/min may not provide a significant change end-tidal CO2, along with equal breath sounds. You
in CO2 because it may not have a significant impact deliver the surfactant dose and begin SIMV plus
on VE. However, the same patient may have ineffec- volume guarantee, PIP 20 cm H2O, PEEP 5 cm
tive spontaneous VT, causing a small change in ven- H2O, target VT 3.5 mL, RR 40 breaths/min, TI
tilator rate to have a larger effect on VE. 0.30 sec, and FIO2 0.40. A postintubation chest
Minimal ventilator settings in patients with RDS radiograph shows good ETT placement midway
are not consistent from institution to institution. between the clavicles and carina, lung inflation to
However, extubation should be considered when the the eighth rib posteriorly, and minimal air bron-
multidisciplinary health-care team is confident that chograms, although there are still some areas of
the patient can support his or her own VE. Trials of atelectasis. A follow-up ABG 30 minutes after initi-
ETT CPAP are not recommended in neonates be- ation of ventilation reveals a pH of 7.40, PaCO2 of
cause the high resistance to gas flow through the 38 mm Hg, PaO2 of 68 mm Hg, and HCO3 of
ETT causes very high WOB that may give the im- 23.2 mEq/L. Because of the recent surfactant de-
pression that the patient is “failing” a spontaneous livery and a good spontaneous respiratory rate,
breathing trial (136), when in fact the patient failed you and the neonatologist agree to lower the rate
the ability to breathe through the ETT. Some publi- to 35 breaths/min, and the follow-up gas is pH
cations have described using short trials of ETT 7.37, PaCO2 41, PaO2 64 mm Hg, and HCO3
CPAP lasting between 3 and 10 minutes. If the pa- 23.4 mEq/L.
tient is able to support his or her own VE without
2831_Ch04_065-110 13/03/14 3:14 PM Page 97
High-Frequency Ventilation down the airway to the alveoli. At each point where
High-frequency ventilation (HFV) uses rapid respira- the pressure waves hit an area of restriction or im-
tory rates (greater than 150 breaths/min) and very pedance, the pressure decreases, causing as much as
small VT (usually less than anatomical dead space) to a 90% drop in delivered pressure (143). HFV can
provide ventilation and lung protection. HFV has been overcome the complication of unequal gas distribu-
used both as an initial therapy for RDS and as a rescue tion by using intra-alveolar communication to help
modality for neonates who fail attempts at conven- more evenly distribute gas from well-inflated alveoli
tional methods of ventilation. When used appropri- to adjacent atelectatic alveoli.
ately, HFV improves oxygenation, CO2 elimination, The complications of HFV are usually caused by
and circulation in infants with RDS (141). The theory the selection or continuance of inappropriate set-
of rapid shallow breathing was suggested in 1915 by a tings. They include the following:
scientist named Yandell Henderson, who observed that • Hypocarbia: HFV, when used appropriately, is
dogs can pant indefinitely while still maintaining nor- very effective at CO2 clearance. This makes it
mocarbia. He did a series of experiments to illustrate easy to inadvertently cause hypocarbia, which
the physiological mechanisms that make HFV an ef- can contribute to lung and brain injury. Blood
fective therapy (142). HFV sends a steady stream of gases should be followed closely, and HFV
very small volume into the airways at a high velocity, should be provided by clinicians familiar with
using relatively low pressures and using PEEP or Paw its use to avoid this complication.
to maintain alveolar stability. Using higher Paw and • Air trapping: With rapid rates, it is possible to
small volumes allows minimizing of overdistention allow inadequate time for exhalation, which will
and underdistention of the lung and ventilating in the cause air trapping. This is most frequently man-
safe window (Fig. 4-9). The net effect of several breaths ifested as auto-PEEP, which can be directly
is that fresh gas will advance down the core of the air- measured in high-frequency jet ventilation
ways to the alveoli, allowing diffusion of gas through (HFJV) or can be presumed by observing chest
the A-C membrane. Exhaled gas will move out along radiographs and the presence of hypercarbia as
the airway walls, in a cyclic pattern around the incom- seen in ABGs.
ing gas and out the large airways. This method of ven- • Excessive Paw: This can occur when HFV is
tilation decouples oxygenation and ventilation, used in patients with very poor compliance.
meaning that changes on the ventilator can be made Once the alveoli are recruited, Paw needs to be
that affect only oxygenation and that have little effect reassessed and decreased if it is excessive. Paw
on CO2, and vice versa. Changing the continuous dis- that is left at a high setting will overstretch the
tending pressure (CDP) will adjust oxygenation, and alveoli and may interfere with gas exchange
making changes in delivered volume will affect CO2 and cardiac output. Chest radiographs allow
clearance. In CV, VE = RR × VT. In HFV, VE = RR × clinicians to visualize lung recruitment to de-
VT2. This means that small changes in volume will have termine when to decrease Paw.
a profound effect on CO2 clearance. When adjusting • Inadequate Paw: Fear of barotrauma and lung
HFV settings to improve CO2 clearance, changes in injury makes it common for PEEP or Paw to
volume will be more effective than changes in the rate. be set too low during HFV, which will lead
The leak around the ETT also helps to facilitate more to alveolar derecruitment and poor oxygena-
effective CO2 removal, with CO2 escaping around the tion and ventilation.
tube rather than having to move through it.
Higher ventilating pressures can be used during There are two types of HFV: high-frequency
HFV because the pressure attenuates as it moves oscillatory ventilation (HFOV) and HFJV (Fig. 4-10).
The physiological mechanisms for the two forms of
HFV are the same, but there are many differences be-
Tracheal Pressure, cm H2O
20
tween the two that make it challenging to understand
and compare them.
15 HFOV allows the clinician to directly set Paw, which
10 HFOV controls oxygenation along with FIO2. During HFJV,
PEEP and PIP are the primary factors that control
5 IMV Paw. Frequency, inspiratory time (TI), and FIO2 are set
HFJV on both devices. During HFOV, amplitude ΔP) and
0 Paw are set, whereas PIP and PEEP are set during
0 0.2 0.4 0.6 0.8 HFJV. These differences limit the ability to extrapolate
Time (seconds) Paw understanding of one device to the other or to com-
Figure 4-9 Pressure Curves for IMV, HFOV, and HFJV pare management strategies during clinical research
2831_Ch04_065-110 13/03/14 3:14 PM Page 98
0.4 seconds and a rate of 5 to 10 breaths/min. the result of a follow-up blood gas shows adequate
Once O2 saturation improves, lung recruitment ventilation, then the HFJV can be disconnected from
using IMV breaths should be discontinued. the ETT and the patient can continue on SIMV.
at 25 wG (175). Cerebral palsy, a broad term for a surviving RDS. For instance, health-care costs for in-
group of motor-impairment syndromes, is not diag- fants less than 32 wG with morbidities are 4.4 times
nosed until 3 to 5 years of age, so data currently avail- greater than for children without morbidities, which
able on its incidence in preterm infants may not emphasizes the importance of preventing long-term
accurately reflect recent changes in neonatal care. A sequelae for premature infants (186). Several thera-
2005 study showed a decrease in mortality but an in- pies have been moderately successful in animal mod-
crease in cerebral palsy from 16% to 25%, with addi- els when treating RDS or preventing CLD, but they
tional increases in the rate of deafness and general are not currently recommended for routine use in
neurodevelopmental impairment (176). Infants sur- preterm infants. These include the following:
viving RDS will require more special education serv-
• Antithrombin
ices and need to be followed closely through those
• Thyroid hormone
services, particularly if they are living in poverty (177),
• Inhaled nitric oxide (iNO)
because they may have less access to resources to im-
• Digoxin
prove cognitive and motor development.
• Diuretics
The major long-term respiratory complication of
a preterm birth is BPD, which occurs in about 20%
of ventilated infants (178). Even in children who do
not develop BPD, pulmonary function tests of those ■ ■ BG Gibbs remained on volume-guarantee SIMV
with RDS at school age show alterations in lung for 9 days. She was extubated on day of life (DOL)
function (179, 180). Prematurity has been a risk fac- 10 to NCPAP plus 5 cm H2O until DOL 15, when she
tor for the development of reactive airway disease was placed on a HFNC for 1 week. She was then
later in life, though studies are unclear on whether changed to an NC at 1 LPM for 9 days at an FIO2 of
RDS alone will increase the risk for wheezing or if 0.21 to 0.28. She is now 29 5/7 wG, and you have
postneonatal health problems and environmental just discontinued her NC.
factors are more important determinants for its de-
velopment (181). In a study of 126 preterm infants,
cough occurred in 80%, wheeze in 44%, rehospital-
ization in 25%, and long-term inhalation therapy in
those who wheeze occurred in 13%, even without
■■ Critical Thinking Questions: BG Gibbs
being diagnosed with BPD (182). 1. Do you think BG Gibbs should have been intu-
One publication suggests five respiratory practices bated so quickly after admission to the NICU?
to improve neonatal outcomes and decrease costs for Were there other interventions you might have
children born before 33 wG. suggested to the physician?
2. How would you assess BG Gibbs for resolution
1. Exclusive use of bubble CPAP of RDS? How would you know that she was no
2. Use of bubble CPAP in the delivery room longer experiencing respiratory distress?
3. Strict intubation criteria for infants with recur- 3. BG Gibbs seems to tolerate conventional ventila-
rent apnea, hypoventilation, and PaCO2 tion well. What are some signs you should look for
greater than 65 mm Hg for more than one that would tell you she should be managed with
ABG test HFV?
4. Strict extubation criteria within 1 hour of sur-
factant delivery or within 2 to 6 hours of
reaching a predetermined extubation criteria
5. Prolonged CPAP without NC oxygen before
35 weeks postmenstrual age (183)
◗● Case Studies and Critical
Early data from this initiative showed it has re-
duced the number of intubations, hypotension due Thinking Questions
to respiratory interventions, incidence of BPD, as
well as earlier extubation, and has decreased equip- ■ Case 1: Baby Boy (BB) Goldstein
ment and surfactant costs. You are the dayshift RT at a level IIIC NICU.
Approximately 2% of the NICU population will de- Three days ago, you attended the delivery of BB
velop sensorineural hearing loss (184). One 2011 study Goldstein, a 550-g, 23 2/7 wG male born to a
noted that hearing loss occurred in 5% of infants, and 22-year-old woman with chorioamnionitis. Apgar
the largest noncongenital risk factor for hearing loss scores were 1 at 1 minute and 3 at 5 minutes. He
was being subjected to more than 5 days of MV (185). showed no signs of respiratory effort in the delivery
Despite the improved survival, there are addi- room, necessitating intubation and administration
tional long-term factors for children and families of exogenous surfactant by 5 minutes of age.
2831_Ch04_065-110 13/03/14 3:14 PM Page 103
Multiple-Choice Questions
1. Which of the following are characteristics of 3. You are caring for a 28 wG boy, now 6 hours
RDS? old. His HR is 140 bpm, RR 65 breaths/min,
I. Surfactant deficiency SpO2 89% on 1 LPM NC, FIO2 0.40. You are
II. Lung hypoplasia completing a respiratory assessment and note
III. Low-compliance chest wall that he has see-saw respirations, mild inter-
IV. Reticulogranular pattern on chest costal retractions, visible xiphoid retractions,
radiograph marked nasal flaring, and expiratory grunting
V. Hypocarbia when you listen with a stethoscope. What is his
VI. See-saw breathing pattern Silverman-Andersen score?
a. I, II, III, IV, V, VI a. 6
b. I, II, IV, VI b. 7
c. I, II, IV, V, VI c. 8
d. I, II, IV, V d. 9
2. You are in the delivery room preparing for the 4. What change in respiratory support would you
delivery of a 27 6/7 wG male. The team leader suggest for the above patient?
for the resuscitation requests that you provide a. Increase FIO2 to 1
respiratory support for the newborn upon de- b. Increase NC to 2 LPM
livery. Which of the following is your preferred c. Change to NCPAP plus 5 cm H2O
plan? d. Intubate and place on A/C, VT 6 mL/kg
a. Begin immediate bag-mask ventilation after 5. Your NICU is rewriting its policy on surfactant-
his arrival to the radiant warmer replacement therapy. You are asked to provide
b. Provide NCPAP via T-piece resuscitator the description of expected positive response
after verifying that he has spontaneous. res- during this pharmacological therapy. Which of
piratory effort the following will you include in the policy?
c. Intubate and provide surfactant treatment a. Improvement in SpO2
within the first 3 minutes of life b. Reduction in FIO2
d. Observe the newborn and provide ven- c. Decreased WOB
tilatory or oxygen support as needed, d. Increased VT during pressure ventilation
based on his ability to support his own e. All of the above
respiration
2831_Ch04_065-110 13/03/14 3:14 PM Page 104
6. You are caring for a 4-day-old infant born at note that her total HR is 142 bpm, RR is
24 5/7 wG. She was given a dose of surfactant 50 breaths/min, and SpO2 is 89%. Exhaled
in the delivery room and extubated to NCPAP volumes are being met at 3 mL during SIMV
of 5 cm H2O, on which she has remained. breaths, with a PIP delivered at 17 to 19 cm
She is now on a variable-flow NCPAP of 6 cm H2O; her exhaled VT with spontaneous breaths
H2O and FIO2 0.70, and her CBG is pH 7.24, is 3.7 mL. BG Guthrie’s RN noted that today’s
PcCO2 56 mm Hg, PcO2 44 mm Hg, HCO3 weight is now 785 g, an increase from the last
23.7 mEq/L. She has been having increased weight 2 days earlier. Her CXR shows lung
periods of apnea, with bradycardia and hypox- inflation to seven ribs, and ABG values from
emia. What is your recommended course of umbilical artery catheter was pH 7.28, PaCO2
action? 54 mm Hg, PaO2 50 mm Hg, and HCO3
a. Intubate and place on SIMV 25 mEq/L. Based on this information, what
b. Intubate, give a second dose of surfactant, would you like to do?
then resume NCPAP a. Nothing: Her vital signs, laboratory test
c. Continue on NCPAP of 6 cm H2O and ob- data, and ventilator measurements are all
serve for 2 to 4 hours, assessing for signs of within acceptable range
improvement in respiratory status b. Increase PEEP to plus 6 cm H2O to improve
d. Change to NIPPV at a rate of 5, with a PIP lung inflation
of 24 cm H2O and a TI of 0.6 seconds c. Increase PIP to 20 cm H2O to increase VT
7. Which of the following are benefits of using delivery
volume-targeted ventilation in neonates with d. Increase VG to 4.0 mL to improve exhaled VT
RDS? e. Increase rate to 40 breaths/min to better sup-
VII. Avoiding overventilation port her spontaneous respirations
VIII. Varying VT based on lung compli- 9. How should Paw be chosen during initiation of
ance changes HFOV?
IX. Avoiding underventilation a. Set to the same value as the measured Paw
X. Promoting more uniform gas delivery on CV
XI. Providing a square waveform pattern b. Use the optimal PEEP strategy to find what
a. I, IV Paw is necessary to avoid hypoxemia
b. I, II, III c. Set 1 to 2 cm H2O higher than the measured
c. I, III, IV Paw on CV
d. I, III, V d. Set 2 to 3 cm H2O below the PIP on CV
8. You are caring for BG Guthrie, a 25 6/7 wG 10. What is the correct initial rate for HFJV?
girl who is now 4 days old. She is intubated a. Set to 420 breaths/min
with a 2.5-cm ETT taped 7.5 cm at the lip, on b. Select higher rates for smaller patients, up to
SIMV with volume guarantee: PEEP plus 5 cm a rate of 660 breaths/min
H2O, RR 35 breaths/min, PIP 18 cm H2O, c. Set the HFJV rate to 420 breaths/min and
volume guarantee 3 mL, and FIO2 0.40. You CMV to 5 or 10 breaths/min
assess her at the beginning of your shift and d. Multiply current rate on the ventilator by 10
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Chapter 5
Apnea of Prematurity
and Bronchopulmonary
Dysplasia
Chapter Outline Key Terms
Chapter Objectives Apnea of prematurity (AOP)
Key Terms Bronchopulmonary dysplasia
Baby Girl (BG) Gibbs (BPD)
Apnea of Prematurity Caffeine citrate
Pathophysiology Central apnea
Clinical Manifestations Central chemoreceptors
Management and Treatment Chronic lung disease (CLD)
Course and Prognosis Corticosteroids
Bronchopulmonary Dysplasia Methylxanthines
Pathophysiology Mixed apnea
Clinical Manifestations Obstructive apnea
Management and Treatment Periodic breathing
Course and Prognosis Peripheral chemoreceptors
Critical Thinking Questions: BG Vitamin A
Gibbs
Case Studies and Critical Thinking
Questions
Review Case 1: BG Stock
Review Case 2: Baby Boy (BB)
Ranger
Multiple-Choice Questions
References
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Chapter Objectives
After reading this chapter, you will be able to:
1. Classify the clinical signs and symptoms of apnea of prematurity (AOP).
2. Differentiate between periodic breathing and AOP.
3. Recommend pharmacological and nonpharmacological treatment for AOP.
4. Assess discharge readiness for a patient diagnosed with AOP.
5. Describe the physiological mechanisms that contribute to the development of the “new bronchopulmonary
dysplasia.”
6. Classify the severity of bronchopulmonary dysplasia (BPD), given a set of patient criteria.
7. Suggest strategies to prevent severe BPD.
8. Describe how the currently recommended strategies for preventing BPD act to preserve pulmonary function.
E
xtremely premature infants are susceptible to There are many causes of apnea in premature
more than just respiratory distress syndrome infants. It typically results from a combination of
(RDS). After survival of the neonatal period, incorrect neural signaling and airway obstruction,
there are other significant respiratory disorders that but it can also be a sign of underlying pathology
can threaten survival without permanent sequelae. (Box 5-1). AOP, specifically, is a developmental
Apnea of prematurity can cause life-threatening
bradycardia and hypoxemia and requires prompt
intervention from health-care providers to prevent res-
Box 5-1 Causes of Neonatal Apnea (5, 8, 16)
piratory and cardiac arrest and neurological damage.
Chronic lung disease has been described in the neona- • Sepsis • Hypertension
tal population for as long as mechanical ventilation • Meningitis • Heart failure
has been used. Bronchopulmonary dysplasia is a form • Necrotizing • Anemia
of chronic lung disease that was primarily caused by enterocolitis (NEC) • Gastroesophageal
positive-pressure ventilation. Since the advent of sur- • Intracranial reflux disease
factant replacement therapy and prenatal corticos- hemorrhage • Abdominal
teroids, this form of lung disease is rarely seen in • Seizures distension
infants other than extremely premature infants with • Asphyxia • Medications (opiate,
severe RDS. As integral members of the neonatal clin- • Congenital magnesium,
ical team, respiratory therapists (RTs) can positively neurological prostaglandin E1)
affect the incidence and severity of these diseases early malformations • Pain
in a patient’s clinical course by minimizing exposure • Hypoxemia • Airway
to excessive oxygen and ventilation and making timely • RDS malformation
interventions when ventilation is insufficient. • Pneumonia • Head and body
• Aspiration position
Apnea of Prematurity • Patent ductus • Hypoglycemia
arteriosus • Hypocalcemia
Apnea of prematurity (AOP) is defined as a • Hypovolemia • Hyponatremia
sudden cessation of breathing that lasts for at least
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stretch receptors that are activated when the lungs Apnea of Prematurity
160
inflate (15), making the normal human response to
140
hypoxia in the form of hyperventilation, tachycar-
120
dia, and peripheral vasoconstriction. Premature in-
100
fants, in contrast, respond to hypoxia with a brief
80 RR
increase in ventilation caused by stimulation of the
60 HR
peripheral chemoreceptors, followed by apnea and
40 Sp02
bradycardia, and they do not appear to increase res-
20
piratory rate in response to hypercapnia (16). This
0
resultant apnea may be the result of hypersensitivity 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30
of the peripheral chemoreceptors to high PaO2 or Seconds
low PaCO2, causing a significant decrease in respi- Figure 5-1 Apnea of Prematurity
ratory rate (17). As bradycardia becomes more pro-
nounced, both systolic and diastolic blood pressures
may fall, which can be associated with a decrease in apnea. Bradycardia occurs in 10% of apneic events
cerebral blood flow (6) and increase the infant’s risk lasting 10 to 14 seconds, in 34% of apnea lasting
for hypoxic brain injury. 15 to 20 seconds, and in 75% of apneas lasting
There is also speculation that certain neurotrans- greater than 20 seconds (21). Bradycardia usually oc-
mitters may be mediators for hypoxic depression, in- curs following apnea with associated desaturation,
cluding adenosine, endorphins, gamma-aminobutyric and once apnea ceases, recovery from bradycardia
acid (GABA), and serotonin. Cytokines involved often precedes recovery of SpO2.
in prostaglandin E2 production have also been impli- Because the clinical picture of AOP relies heavily
cated. Knowledge of these chemicals may assist on bedside monitoring systems, it is essential to have
health-care teams in creating more specific pharma- sensitive systems that provide accurate information
cological therapies for AOP, with fewer systemic side to the bedside clinicians, while also filtering out erro-
effects. neous or incorrect data. There are many respiratory
Regardless of the true cause of premature hypoxic monitoring techniques available. The most simple is
respiratory depression, the clinical manifestations an abdominal pressure sensor: A diaphragm taped to
are essentially the same, and the care and course of the abdominal wall transmits a small pressure change
AOP is similar for all infants. to a sensor that sounds an alarm (or signals) if ab-
dominal movement stops for a defined time period.
Clinical Manifestations Most neonatal unit cardiorespiratory monitors use
The definition of AOP encompasses the clinical signs transthoracic impedance pneumonography: Elec-
of the disease, including apneas of more than 20 sec- trodes are placed on either side of the infant’s chest
onds with bradycardia and hypoxemia for 4 seconds above and below the diaphragm. As gas flows in and
or more. Bradycardia is defined as a HR less than out of the lungs, the electrical impedance changes be-
two-thirds of baseline, and hypoxemia is SpO2 less tween the electrodes. The monitor can use that imped-
than 80% (18). An easier method for rapidly evalu- ance data to display a live respiratory waveform and
ating apnea clinically was described by Finer et al. a calculated respiratory rate. Monitoring systems are
as cessation of breathing for greater than 20 seconds continuously seeking to improve the technology for
or cessation of breathing for greater than 10 seconds the smallest infants, and several quality-improvement
accompanied by either a heart rate (HR) of less than plans have been published to minimize false alarms
100 beats per minute (bpm) or SpO2 less than 80% and improve accuracy in identifying central apnea
(19) (Fig. 5-1). Either of these clinical signs needs (Evidence in Practice 5-1).
immediate medical attention. Every apneic episode should be monitored and
In an effort to better characterize the severity of ap- documented in the patient’s chart because respira-
neic episodes and their effect on long-term outcomes, tory or pharmacological treatment strategies and
the CHIME study created advanced definitions of ap- discharge decisions will be based on the frequency
neic episodes. They delineated between conventional of apneic episodes and required interventions.
apneic events and extreme apneic events: Conven- Any care provider should intervene when
tional apneic events are those with a duration of 20 to clinically significant apneas are observed (i.e.,
29 seconds or an HR of less than 50 to 80 bpm for provide tactile stimulation) and document any inter-
5 to15 seconds; extreme apneic events are those with ventions necessary to reverse apnea. The patient’s
a duration of 30 seconds or longer or an HR less than clinical picture surrounding an increase in apneic
50 to 60 bpm for 10 seconds or more (20). events will help clinicians determine the desired di-
Bradycardia does not always occur with apnea, agnostic testing and clinical intervention. Interven-
although it is more likely with longer duration of tions may include a septic screen, full blood count,
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retinopathy of prematurity, and neurocognitive de- The first is delivery of mild positive pressure in the
fects (30). Caffeine also appears to be safer and more upper airway to prevent obstructive apnea; the sec-
effective than other methods of treating apnea, such ond is tactile stimulation in the nares as a way to pre-
as kinesthetic stimulation (31) and pharmacological vent central apnea. These can be prescribed without
stimulants such as doxapram (32). the addition of supplemental FIO2. Additional oxy-
Caffeine citrate is a once-a-day therapy adminis- gen delivery via NC can also serve to prolong the
tered intravenously or orally, with a loading dose of time period between apnea and desaturation. In a
10 to 20 mg/kg and a daily maintenance dosage of review of 52 infants prescribed an NC for oxygen de-
5 to 10 mg/kg (33). Caffeine citrate has a very long livery, 22 (11.8%) were prescribed room air through
half-life, although it appears to vary with postmen- NC intentionally, presumably to treat AOP.
strual age and current weight. The half-life has ranged
from 52 to 101 hours for patients between 30 and Noninvasive Ventilation
33 wG (34–36), with a standard deviation of approxi- Nasal continuous positive airway pressure
mately 24 hours. This is important when weaning and (NCPAP) is an established therapy for adult obstruc-
discontinuing caffeine therapy, because it may take tive sleep apnea, and the mechanics and physiological
a week or more to return to subtherapeutic serum mechanisms are the same in neonatal patients. During
caffeine levels that will allow clinicians to observe true obstructive or mixed apnea, NCPAP provides a posi-
resolution of AOP without pharmacological therapy. tive pressure throughout the respiratory cycle that in-
The side effects of methylxanthines include tachy- creases pharyngeal pressure, which can splint the
cardia, arrhythmias, irritability and crying, feeding upper airway with positive pressure and reduce the
intolerance, and seizures. These side effects, which are likelihood of upper-airway collapse leading to obstruc-
only evident when methylxanthine therapy reaches tion and subsequent apnea (40, 41). Tactile stimulation
toxic levels, are rarely seen with caffeine because caf- in the nares from the device itself may also contribute
feine has a wide therapeutic margin. There were re- to the effect as well as to the improvement of oxygena-
ports of an increased risk of necrotizing enterocolitis tion by providing alveolar stabilization and improved
(NEC) with methylxanthine use in premature infants, FRC. Higher FRC will also prolong the time period
which have not been substantiated for caffeine despite from apnea to desaturation and bradycardia. An
several large multicenter trials of caffeine citrate for NCPAP setting of 4 to 6 cm H2O is usually adequate.
treatment of AOP (37). The increased oxygen con- The patient interface and delivery devices for
sumption has the potential to decrease weight gain NCPAP are the same as those discussed in Chapter 4.
in the short term (31), but it is not substantial in the It is not clear which type of NCPAP device is more
long term. effective at minimizing apneic episodes, although one
small study showed evidence that a variable-flow
Blood Transfusions NCPAP device may be superior (42). CPAP is only ef-
Anemia, another frequent problem in preterm infants, fective at alleviating obstructive apneas and will have
is a potential precipitating factor for AOP. Blood no effect on central apnea.
transfusions have been demonstrated to improve ir- Noninvasive positive-pressure ventilation (NIPPV)
regular breathing patterns in preterm infants, although may be a useful method of augmenting the beneficial
the potential risk of blood transfusion has limited its effects of NCPAP in preterm infants with apnea that
use as treatment for apnea. The presumed physiolog- is frequent or severe. It is delivered in a manner similar
ical mechanism is that enhanced oxygen-carrying ca- to that of NCPAP, with the addition of a peak inspi-
pacity, as with red cell transfusion, may decrease the ratory pressure (PIP), inspiratory time (TI), and infla-
likelihood of hypoxia-induced respiratory depression. tion rate or respiratory rate (breaths/min). Its use
One study of 67 infants showed that transfusion appears to reduce the frequency of apneas more
was associated with fewer apneic events detected by effectively than NCPAP and may be more effective at
the bedside monitor and that apneas were less fre- reducing work of breathing (43).
quent with higher hematocrit levels (38). Blood
transfusions can be considered an appropriate ther- Invasive Positive-Pressure Ventilation
apy only in the presence of clinically significant Intubation and invasive mechanical ventilation (MV)
apnea and with evidence of low hematocrit. may be required for those infants who do not respond
to noninvasive forms of ventilation or pharmacologi-
Nasal Cannula cal therapies or who are experiencing severe refractory
The use of an NC to deliver pressure or gas episodes. As with other preterm infants, a synchro-
flow to reduce the frequency of apnea and desatura- nized ventilator mode and minimal ventilator settings
tion has not been tested adequately, although its use should be used to allow spontaneous ventilatory ef-
has become common for patients with AOP (39). forts and to minimize the risk of ventilator-induced
The mechanism of action is thought to be twofold. lung injury (VILI).
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from the hospital can be delayed until caffeine is dis- ■ ■ At 35 3/7 wG, BG Gibbs is ready to be discharged
continued and serum tests verify it is at subtherapeutic to home. She has been on room air for 3 weeks and
levels, which will take at least 5 to 7 days. If apnea has been without caffeine therapy for 10 days with-
reappears after cessation of caffeine, caffeine should out apneic incidence. Evaluation must now be made
be reinstituted, and the process should be repeated in regarding her level of lung disease and need for sup-
approximately 2 weeks’ time. Discharge from the hos- port at home.
pital should be delayed if there is persistence of apneic
events with associated bradycardia and hypoxemia.
An alternative to a prolonged hospital stay could
include a discharge home with cardiorespiratory mon- Bronchopulmonary Dysplasia
itoring until 43 to 44 weeks postmenstrual age. The
home monitor emits an alarm during a prolonged Any pulmonary disease that results from a neonatal
apneic episode, alerting a caregiver to a potentially respiratory disorder is called chronic lung disease
dangerous condition so that the caregiver can inter- (CLD) (57). Bronchopulmonary dysplasia (BPD) is a
vene in a timely fashion. type of chronic lung disease, currently defined as the
Whatever the discharge care plan, family educa- need for supplemental oxygen for at least 28 days
tion and training is essential because apnea at home after birth, assessed at discharge or when the baby
is a frightening event. Families may also be com- is close to his or her estimated full-term age.
forted by the cardiorespiratory monitors used in the The first mention of lung disease caused by MV
hospital, which will be absent at home. Parents and during hyaline membrane disease (HMD) was in
caregivers should be instructed on the simple stimu- 1967. The Stanford Premature Infant Research Cen-
latory techniques required to resolve apneic events ter studied 30 patients with HMD with cyanosis and
and reassured that apneic events rarely result in apnea who were not responsive to noninvasive oxy-
death and do not put their child at an increased risk gen therapy. The result of their findings, which they
of SIDS (8, 23, 30). Their knowledge of access to called BPD, was described as the “prolongation of
emergency services should also be reviewed, and they the healing phase of RDS combined with a general-
should be provided with a basic life-support course ized pulmonary oxygen toxicity involving mucosal,
before their infant is discharged. alveolar, and vascular tissues” and was seen in in-
Determining the long-term outcomes of AOP has fants receiving FIO2 of 0.80– to 1.0 for more than
been challenging because there are many other poten- 150 hours (58).
tial coexisting causes for neurological injury in pre- In 1985, it was described as occurring in 15% to
mature infants (described in Chapter 8). Prolonged 38% of infants weighing less than 1,500 g and requir-
apnea and bradycardia are known to decrease sys- ing MV for RDS (59). The description of the cause
temic blood pressure and lead to cerebral hypoperfu- of BPD in the 1980s included the iatrogenic injury
sion, which can contribute to hypoxic-ischemic injury from oxygen toxicity and barotrauma from MV, as
of the immature brain (52). However, infants born well as compounding factors such as premature
prematurely have a higher rate of central nervous sys- birth, fluid overload, PDA, damage from severe pul-
tem injury such as periventricular leukomalacia and monary disease, and familial asthma. The incidence
intraventricular hemorrhage (IVH), both of which of diagnosis of BPD decreased significantly between
cause apnea. It has been difficult for studies to estab- 1993 and 2006, but it appears that the care required
lish whether apnea was a cause of a cerebral dysfunc- for infants diagnosed with BPD increased (60). With
tion or a result of it. the addition of surfactant replacement therapy and
Premature infants have delayed mental and motor the use of antenatal glucocorticoids in the 1990s, the
development regardless of the presence of AOP (53); neonatal research community considered that the
some case comparisons reported no difference in initial description and characteristics of BPD might
outcome of infants with apnea, whereas others report no longer reflect what was seen in the patient popu-
evidence of a higher incidence of general neurodevelop- lation. The number of BPD diagnoses had decreased
mental delays, cerebral palsy, and blindness (32, 54, 55) in older premature infants, but researchers noted an
in patients with frequent apnea. There was also con- increase in the diagnoses of BPD in younger popu-
cern that caffeine citrate may have a negative effect lations. Reports in the early 2000s indicated that al-
on neurodevelopmental outcome, but the CAP trial most two thirds of infants who acquire BPD weigh
found no difference in outcomes at 18 months or less than 1,000 g and are less than 28 wG at birth,
5 years in the rates of death, motor impairment, be- and they frequently did not have a prior history of
havior problems, poor general health, deafness, or severe RDS. Clinical observation of extremely
blindness (56). It also had the clear benefit of reducing premature and extremely low birth weight (ELBW)
the frequency of BPD, a chronic lung disease of pre- infants who developed BPD showed they often re-
maturity discussed in the next section. quired little supplemental oxygen during their initial
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There are certain risk factors that increase the Table 5-2 Characteristics of Old and New BPD
likelihood for more severe BPD, which include the
following: Old BPD New BPD
the early initiation of low-dose nitric oxide does not controlled trials, thiazides are the diuretics of
prevent the subsequent development of BPD (127). choice in ventilator-dependent infants with evolving
In an effort to better understand the risks and or established BPD (133). Loop diuretics, such as
benefits of iNO, a recent multicenter randomized, furosemide, carry additional risks when used spar-
double-blind, placebo-controlled trial of iNO for ingly to acutely treat pulmonary edema; these in-
preterm infants weighing less than or equal to 1,250 g clude hearing dysfunction, calcium deposition in the
and who required ventilatory support between 7 and renal tubules, higher incidence of PDA, and low
21 days of age was conducted. Infants initially re- bone marrow density support (134). Furosemide can
ceived 20 ppm of study gas for 48 to 96 hours, and also be aerosolized, with a one-time dose of 1 mg/kg
the doses were subsequently decreased to 10, 5, and used to transiently improve pulmonary mechanics in
2 ppm at weekly intervals, with minimum treatment preterm neonates with established CLD. However,
duration of 24 days. The primary outcome was sur- there is not enough information available regarding
vival without BPD at 36 weeks postmenstrual age. oxygenation and pulmonary mechanics to support
The rate of survival without BPD was higher in chronic administration of aerosolized furosemide
the iNO-treated group, and there was a shorter (135). Regardless of the type or method of diuretics
duration of hospital stay and less need for supple- delivery, care should be taken to prevent electrolyte
mental oxygen therapy (128). There were no short- imbalance when using them.
term safety concerns. Follow-up of these infants at
1 year showed that those treated with iNO received Bronchodilators
significantly fewer bronchodilators, inhaled steroids, Patients with BPD have increased airway resistance
systemic steroids, diuretics, and supplemental oxy- caused by smooth muscle hypertrophy and hyper-
gen after discharge from the NICU (129). Follow- reactivity. Adrenergic bronchodilators stimulate
up at 2 years of age showed no significant increase ß2-adrenergic receptors on airway smooth muscles,
in neurodevelopmental impairment when compared thus relaxing the muscle and reversing the airflow
with placebo-treated infants (130). These recent find- obstruction. Albuterol and salbutamol are the most
ings may affect the use of iNO in premature infants commonly used bronchodilators in the neonatal
at high risk for BPD. population. The side effects most seen with bron-
Despite these studies, there is insufficient consis- chodilators are tremors, tachycardia, and hyperten-
tent evidence to support the routine use of iNO as a sion. The use of bronchodilators does not show a
rescue therapy for the treatment of RDS, although significant improvement in mortality or prevention
it appears that there is no increased risk of IVH or of CLD (136). As with other patient populations,
neurodevelopmental impairment with its use. Its use bronchodilator therapy should be limited to infants
to prevent BPD is promising, but further evidence with evidence of bronchospasm and continued only
is needed (131, 132). if there is a clinical response to therapy (123).
Treatment of Pulmonary Edema Course and Prognosis
BPD is complicated by alveolar edema. Increase in The prognosis for individual patients with BPD is
fluid intake, capillary leak from inflammation caused relatively unpredictable, and the course can vary
by infection or from VILI, or volume overload widely. Extremely premature infants treated with
caused by left-to-right shunting through a PDA can surfactant and corticosteroids are just beginning
all contribute to pulmonary edema. Restriction of to reach adulthood, so there has not been time for
fluids and diuretics is a commonly used strategy to an adequate evaluation of respiratory outcome.
prevent and treat pulmonary edema. The benefits that should be evident as the result of
better care may be obscured by the improvement
Fluid Restriction in the survival of extremely premature and ELBW
Standard management of infants with BPD usually infants. Infants with BPD exhibit some degree of
includes moderate fluid restriction (120 to 130 mL/ obstructive lung disease that can persist into ado-
kg/day) to help prevent interstitial alveolar edema. lescence and young adulthood. Evidence for this in
Fluid management needs to be monitored closely to early in childhood is repeat hospitalizations, ab-
ensure adequate caloric intake for growth (75). normal pulmonary function results, and the need
for home supplemental oxygen. For some, pul-
Diuretics monary dysfunction will continue to manifest into
Diuretics potentially benefit pulmonary edema by school age and adolescence as airway hypersensi-
increasing reabsorption of fluid from the lung. The tivity; wheezing; and abnormalities in pulmonary
two most common diuretics used in BPD, loop function, radiographic evidence, and emphysema-
diuretics and thiazides, differ in their primary site tous symptoms comparable to chronic obstructive
of action on the nephron. Despite few randomized pulmonary disease (COPD).
2831_Ch05_111-134 13/03/14 3:09 PM Page 127
well as poor cognitive outcomes during early child- 3. How might her course have been different had you
hood and school age (154). Higher severity of BPD is provided early CPAP without intubation and early
correlated with the presence of developmental delay surfactant in the delivery room? How might it
(151). BPD constitutes a major cause of poor neuro- differed if she had been given corticosteroids to
motor outcomes at 6 months of age, but improve- help facilitate weaning and extubation from MV?
ments in motor outcomes are seen over time (155).
Economic Impact
Chronic health problems associated with BPD have a Case Studies and Critical
major impact on families’ daily lives after the neonatal
period. Compared with families of full-term babies, Thinking Questions
more parents of children with BPD felt that the child’s
health affected the pastimes of other family members ■ Case 1: BG Stock
and created a significant burden for families far be- You are the floating RT in a rural hospital with a
yond the neonatal period (148). Home oxygen can also level II special care nursery. You are called by the
adversely impact the quality of life of families (146) charge registered nurse (RN) in the special care
and incur greater costs, mostly for prescriptions and nursery to help assess a late-term infant born yes-
respiratory-related care, despite not making a signifi- terday. BG Stock is 33 2/7 wG. The RN called you
cant difference in clinical manifestations (144). because the baby seems to have had a string of
In contrast to other chronic respiratory diseases of desaturation episodes in the last several hours.
childhood, there seem to be minimal health disparities You agree to come and stay in the nursery to ob-
related to socioeconomic status, sex, and race/ethnicity serve BG Stock’s behavior. As you are standing
(147), meaning that care and resources appear to be across the room, with her in a radiant warmer, you
evenly distributed for patients with BPD. watch the monitor appear to show rapid breathing
at 70 breaths/min and then the respiratory tracing
flat lines. You look at the infant’s chest and cannot
■ ■ One year later, Susan Gibbs returns for the NICU see any movement. The monitor begins to alarm
graduation party. She has brought BG Gibbs and at 15 seconds of apnea, and the alarms are joined
her father, who recently returned from deployment. by additional alarms for desaturation. After another
BG Gibbs is now 18 pounds and has been relatively 5 seconds, BG Stock’s HR drops from her base-
healthy. She required one overnight hospitalization line 140 to 100 bpm.
during the winter months for difficulty breathing,
which they attributed to some mild airway hyperre- • What should you do?
activity. She was not given any additional home • Do you think this is AOP? Why or why not?
medications to treat her BPD. BG Gibbs’s neurologi- • What would be the best next course of action?
cal and motor development is delayed, but she is ■ Case 2: Baby Boy (BB) Ranger
meeting the developmental milestones within the You are working in the pediatric intensive care unit
normal limits if her age is adjusted to compensate (PICU) of a large regional pediatric hospital and re-
for her prematurity. She is just starting to crawl and ceive notification of a transfer arriving from a level
attempts to place your hospital identification badge in IIIB NICU that is closely affiliated with your hospi-
her mouth when you pick her up to hold her. Susan tal. BB Ranger is being transferred to be evaluated
expresses her gratitude to the NICU team for all by the pediatric pulmonary team for failure to wean
the work they did for her and her baby during their from MV and evaluation for a tracheostomy tube.
10-week stay in the hospital. He is an ex-25 wG African-American baby who is
now 94 days old. He has a history of RDS and
received three doses of Infasurf. He has been ex-
tubated three times: The first extubation was on
■■ Critical Thinking Questions: BG Gibbs DOL 9; he was reintubated on DOL 14 for severe
1. What strategies were used with BG Gibbs during AOP; he was weaned and extubated again on
the early course of BPD that may have helped min- DOL 27. He was reintubated on DOL 46 for sus-
imize its severity? What additional strategies could pected sepsis and extubated on DOL 60. On DOL
have been used? What things were done that 75, he was intubated in the operating room for an
could have contributed to her developing BPD? inguinal hernia repair operation and has not been
2. What discharge training should her parents be extubated since his surgery.
provided, and what additional home care support
• Based on the information provided to you by
might be needed? How might the NICU team as-
the transport team, what is BB Ranger’s BPD
sess parental readiness for discharge to home?
status?
2831_Ch05_111-134 13/03/14 3:09 PM Page 129
MULTIPLE-CHOICE QUESTIONS
1. Which of the following is not a characteristic III. She may be septic
of AOP? IV. She should be prescribed caffeine
a. A sudden cessation of breathing citrate
b. Lasts for greater than 20 seconds V. She should not be discharged tomorrow
c. Accompanied by bradycardia a. I, III, IV, V
d. Accompanied by hypoxemia b. I, II, IV
e. Occurs only in infants younger than 30 wG c. I, V
2. What is the difference between periodic breath- d. III, V
ing and AOP? 5. What are characteristics of the “new BPD”
a. Periodic breathing is a benign breathing pat- that make it different from the traditional form
tern; AOP is a significant breathing disorder. of BPD, described in 1967?
b. Periodic breathing is associated with an in- a. Overwhelming evidence of alveolar
crease in PaCO2 and no change in PaO2; hypoplasia
AOP is associated with a decrease in PaO2 b. Dysfunction of the alveolar capillary
and no change in PaCO2. membrane
c. Periodic breathing only occurs in full-term c. Emphysematous changes to the alveoli
infants; AOP occurs in premature infants up typical of lung injury
to 37 weeks postmenstrual age. d. Airway injury present
d. Periodic breathing resembles fetal breathing; 6. You are caring for a baby boy, born at 24 3/7
AOP resembles Cheyne-Stokes respiration. wG, who is now 36 weeks postmenstrual age.
3. You respond to an apnea alarm on a patient He was intubated and on supplemental oxygen
who is 33 weeks postmenstrual age and on no for the first 35 days of life. He is now on
supplemental oxygen. When you arrive at the NCPAP plus 7 cm H2O at 0.28 FIO2. Classify
bedside, her HR is 90 bpm, and the SpO2 is the severity of his BPD.
79%. What should you do first? a. Mild
a. Observe until the HR is less than 60 bpm b. Moderate
b. Call the nurse and physician to the bedside c. Severe
c. Provide tactile stimulation d. He doesn’t have BPD
d. Begin PPV 7. Which of the following patients should be
4. Your patient begins breathing again. You doc- considered to receive corticosteroid therapy?
ument this in the patient’s chart and note that a. A 3-day-old neonate, born at 26 wG,
in the last 4 hours there were five episodes of currently on SIMV
apnea with bradycardia and hypoxemia. You b. A 14-day-old neonate, born at 34 wG, on
notify the nurse of your intervention, and the NC 0.40 FIO2
nurse tells you that the patient is scheduled to c. A 28-day-old neonate, born at 24 wG,
go home tomorrow. What are your concerns currently on SIMV
for this patient? d. A 5-day-old neonate, born at 27 wG,
I. She likely has AOP currently on NCPAP
II. She should be discharged on a home
cardiorespiratory monitor
2831_Ch05_111-134 13/03/14 3:09 PM Page 130
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Matern Child Health J. 2011;15(suppl 1):S17-S26. respiratory disease during the first 2 postnatal weeks in
71. Chess PR, D’Angio CT, Pryhuber GS, et al. Pathogenesis extremely premature infants. Pediatrics. 2009;123(4):
of bronchopulmonary dysplasia. Semin Perinatol. 2006; 1124-1131.
30(4):171-178. 92. Kaempf JW, Campbell B, Brown A, et al. PCO2 and
72. Valieva OA, Strandjord TP, Mayock DE, et al. Effects of room air saturation values in premature infants at risk
transfusions in extremely low birth weight infants: a retro- for bronchopulmonary dysplasia. J Perinatol. 2008;
spective study. J Pediatr. 2009;155(3):331-337.e1. 28(1):48-54.
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Chapter 6
Disease of Full-Term
Infants Sarah Mola, MD
Gary Oldenburg, RRT-NPS
Shannon Polin, BS, RRT
Webra Price-Douglas, PhD, CRNP, IBLC
Chapter Objectives
After reading this chapter, you will be able to:
1. Describe the physiological mechanism that causes failure of the transition from fetal circulation to adult
circulation at delivery.
2. Evaluate oxygenation in a patient with persistent pulmonary hypertension in the newborn (PPHN) and
recommend strategies to improve hypoxemia.
3. Recommend therapies to decrease pulmonary vascular resistance (PVR) in a newborn with severe
PPHN.
4. Assess the effectiveness of inhaled nitric oxide (iNO) therapy and recommend necessary changes.
5. Determine whether a patient in hypoxic respiratory failure should be cannulated and placed on extracor-
poreal life support (ECLS).
6. Explain the ventilator support needed for a patient receiving ECLS.
7. List five risk factors associated with increased risk of meconium-stained amniotic fluid (MSAF) and
subsequent development of meconium aspiration syndrome (MAS).
8. Describe the changes to delivery room management needed for an infant with MSAF.
9. Specify the most common signs and symptoms of compromise in an infant with MSAF.
10. Recommend respiratory interventions for an infant with MAS.
11. Identify the common causes of decreased fetal lung fluid absorption at delivery.
■■ Baby Boy (BB) Porter fetal to extrauterine cardiac and pulmonary function.
The most severe of these is persistent pulmonary hy-
pertension (PPHN), and the most common known
You arrive for an evening shift and receive a report on
cause is meconium aspiration syndrome (MAS). A
a 3.5-kg full-term male, BB Porter. He was admitted
less severe form of respiratory distress is transient
to your level IIID neonatal intensive care unit (NICU)
tachypnea of the newborn (TTN). These disorders
12 hours ago from a rural hospital for cyanosis,
are challenging to predict and prevent, and their
tachycardia, hypoxia, grunting, and retractions.
severity can vary widely. The role of the respiratory
He was placed on nasal continuous positive airway
therapist (RT) who cares for these patients is assisting
pressure (NCPAP) device, 5 cm H2O for transport,
in maintaining oxygenation and ventilation, minimiz-
with an umbilical arterial blood gas (ABG) value of pH
ing noxious stimulation, and assessing and adjusting
7.35, partial pressure of carbon dioxide (PaCO2) of
support frequently to prevent hypoxemic respiratory
42 mm Hg, HCO3 of 22.9 mEq/L, partial pressure of
failure.
oxygen (PaO2) of 50 mm Hg. His oxygen saturation
(SpO2) was 89% on a fractional concentration of
inspired oxygen (FIO2) of 0.90. Persistent Pulmonary Hypertension
of the Newborn
Persistent pulmonary hypertension of the newborn
M
ost babies make the transition to ex- (PPHN) is a syndrome with severe hypoxemia and
trauterine life independently and without high pulmonary artery pressures that occurs when
complications. Some (10%) need some sort the pulmonary vascular resistance (PVR), normally
of assistance. Full-term newborns (those delivered high in utero, fails to decrease at birth. The term orig-
between 38 and 42 weeks of gestation [wG]) rarely inally used to describe this syndrome was persistent
require resuscitative efforts in the delivery room be- fetal circulation, which accurately describes the cause
cause they have less risk of complications than do of PPHN but does not as accurately describe the
preterm newborns. Those who do, particularly those pathophysiology of the disease. The condition usu-
who are admitted to a special care nursery, are usu- ally presents at birth or shortly after and is charac-
ally prenatally diagnosed with congenital abnormal- terized by a failure to establish adequate pulmonary
ities, many of which are discussed in Chapters 9 and systemic oxygenation. Without treatment, this
to 12. Full-term babies admitted to the hospital for can cause severe cardiac dysfunction, multiorgan
reasons not associated with congenital abnormalities dysfunction, and death.
usually present with some varying levels of respira- PPHN primarily affects full-term and near-term
tory distress that require close monitoring or inter- neonates, although some premature neonates at less
vention. This respiratory distress is usually caused than 32 wG show echocardiographic evidence of
by a failure to complete the normal transition from PPHN (Special Population 6-1). The incidence of
2831_Ch06_135-164 13/03/14 3:25 PM Page 137
reflex. The successful transition to active breathing and Chapter 9), congenital cystic adenomatoid
increased pulmonary oxygenation causes a 10-fold in- malformation of the lung (CCAM), renal agen-
crease in pulmonary blood flow, resulting in dilation esis (failure of one or both kidneys to develop),
of the pulmonary vessels and a decrease in PVR (9). some instances of oligohydramnios (low levels
Ventilation also increases pH within the pulmonary of amniotic fluid), and intrauterine growth
vascular bed, further decreasing PVR. restriction.
When the umbilical cord is clamped at birth, it • Maldevelopment refers to the situation in which
removes the low-resistance placental circuit and the lungs develop normally, but the pulmonary
greatly increases SVR. Other factors at delivery that arteriole muscle layer is abnormally thick and
increase SVR are a catecholamine surge associated grows in smaller vessels that normally have no
with birth and cutaneous vasoconstriction from the muscle cells. It appears that vascular mediators
cold extrauterine environment. The increased SVR stimulate maldevelopment of the pulmonary
forces blood back into the lower extremities and in- vasculature. When compared with healthy con-
creases pressure on the left side of the heart. This trol patients, infants with severe PPHN have
pressure forces the flap of tissue in the left atrium to higher plasma concentrations of vasoconstrictor
close the foramen ovale. Within the first 24 hours chemical mediators and lower concentrations of
after birth, pulmonary pressures decrease to half that vasodilator mediators (13). Conditions associ-
of systemic levels. ated with PPHN caused by vascular maldevel-
opment include post-term delivery and MAS. In
Changes to Fetal Circulation During PPHN these disorders, the pulmonary vasculature re-
When certain conditions develop before, during, or sponds poorly to oxygen and ventilation, which
after birth, the normal postnatal adaptation of the normally produce a decrease in PVR. Excessive
pulmonary vasculature may be impeded and result perfusion of the lung during fetal development
in sustained high pulmonary arterial pressure. When because of constriction of the ductus arteriosus
pulmonary pressure is higher than systemic pressure, or obstruction of the pulmonary veins may also
blood will shunt from the right side of the heart to predispose fetuses to maldevelopment PPHN.
the left, as in fetal life, through the foramen ovale or • In maladaptation, the pulmonary vascular bed is
ductus arteriosus, and result in systemic hypoxemia normally developed. However, adverse perinatal
and cyanosis. Hypoxemia, hypercarbia, and acidosis conditions cause active vasoconstriction and in-
all act to increase PVR, so right-to-left shunting will terfere with the normal postnatal reduction in
create a cycle that continues to increase pulmonary PVR. These conditions include perinatal depres-
artery pressure, which becomes challenging to halt sion, pulmonary parenchymal diseases, and bac-
and reverse. terial infections, such as group B Streptococcus
There are chemical mediators deriving from the pneumonia (discussed in Chapter 7), and other
pulmonary vascular cells, known as endothelium- less common malformations, such as vein of
derived mediators, which play important roles in the Galen arteriovenous malformations (14). It may
regulation of PVR at birth (10, 11). These include also be caused by perinatal stressors including
nitric oxide (NO), prostacyclin, and endothelin. NO hypoxia, hypoglycemia, and cold stress (15).
is thought to be the most important regulator of vas-
cular tone during the transition to extrauterine life; Clinical Manifestations
in PPHN, there appears to be limited endogenous PPHN should be suspected in any newborn infant
synthesis of NO. Prostacyclin is a vasodilator pro- who exhibits instability in oxygenation or progressive
duced by the pulmonary vessels and stimulated by cyanosis shortly after delivery, usually within the first
the onset of breathing at birth. Endothelin is a po- 12 to 24 hours of life. The diagnosis is confirmed with
tent vasoconstrictor found in high levels in the fetus the history, physical examination, chest radiograph,
and in neonates with PPHN. preductal and postductal blood gases, hyperoxia test,
Classifications of PPHN and echocardiogram. Typically, PPHN should be sus-
pected if there is no history or other pulmonary symp-
In 1984, Geggel classified PPHN in three groups,
toms, making hypoxemia seem out of proportion to
distinguished by the underlying cause of pulmonary
the degree of lung disease. Differentiation between
hypertension: underdevelopment, maldevelopment,
lung disease, PPHN, and cyanotic congenital heart
and maladaptation (12).
disease can be difficult, so a systematic approach to
• Underdevelopment is characterized by hypoplastic hypoxemic neonates is needed for a timely and
pulmonary vasculature from pulmonary hypopla- accurate diagnosis of PPHN.
sia, which produces a relatively fixed level of Patients are usually term or near term, with
pulmonary hypertension. Typical lesions include no previously diagnosed signs of congenital respira-
congenital diaphragmatic hernia (discussed in tory or cardiac disease. PPHN frequently occurs in
2831_Ch06_135-164 13/03/14 3:25 PM Page 139
Respiratory Support
Management and Treatment
The objectives in managing PPHN are to correct Neonates with moderate respiratory distress and hy-
the underlying disease, maintain adequate systemic poxemia may need ventilation support. Mechanical
blood pressure, decrease PVR, maintain optimal ventilation (MV) can support oxygen delivery, provide
oxygen delivery to the tissues, normalize pH, and alveolar stability, and assist in ventilation during res-
minimize ventilator-induced lung injury (VILI). Care piratory failure. The goal of MV should be normox-
should be tailored to the degree of hypoxemia and emia, normalization of pH, avoiding hypercapnia, and
cardiopulmonary instability. Some patients with mild prevention of VILI. Recommendations for respiratory
PPHN respond favorably to oxygen, whereas others support can be found in Table 6-1.
require sedation and analgesia, mechanical ventila-
tion, inotropes and pulmonary vasodilators, and Conventional Mechanical Ventilation
complete cardiopulmonary support to prevent death. Typically, the strategy of mechanical ventila-
Because PPHN is often associated with parenchymal tory support depends on the degree of lung disease
lung disease or systemic illness, respiratory therapy and the patient’s response to treatment. In general,
should target the underlying disease. Support should patients with less severe pulmonary impairment are
be provided as needed, as well as frequent assessment treated with conventional mechanical ventilation
that focuses on restoring independent and normal (CMV) and ventilated to maintain PaCO2 of 35 to
cardiopulmonary function and avoiding lung injury 45 mm Hg. Studies of animal models and babies with
or adverse effects on systemic perfusion. It is impor- PPHN demonstrated that low PaCO2 and an increase
tant to remember that the heart and lungs function in pH will cause pulmonary vasodilation (20, 21).
as an integrated system, and changes to one will usu- These benefits are only temporary, however, and will
ally affect the other. The discussion that follows will increase the risk of VILI and other detrimental sys-
focus on the management of patients with idiopathic temic effects (Box 6-3). The use of hyperventilation
PPHN who have no underlying disease or precipitat- to treat PPHN is no longer recommended because of
ing cause of PPHN. See Box 6-2 for a summary of other methods of pulmonary vasodilation.
treatment strategies for PPHN. Synchronized ventilation should be used, and res-
piratory effort should be encouraged as long as it
doesn’t negatively impact oxygenation. PEEP is es-
Box 6-2 Management Strategies for PPHN sential to stabilize alveoli and prevent atelectasis.
Pressure ventilation is common in infants and should
• Oxygen to maintain preductal PaO2 90 to target a tidal volume (VT) of at least 4 to 8 mL/kg
120 mm Hg body weight. PaO2 should be used to adjust FIO2
• CMV to produce normocapnia or mild levels. Preductal and postductal SpO2 should be used
hypocapnia to monitor acute changes in oxygenation and to
• HFOV when high pressures or rates are identify when right-to-left shunting of blood through
required with CMV the patent ductus arteriosus (PDA) occurs, as
• Pulmonary vasodilators, such as iNO demonstrated by a difference of greater than 10% in
• Maintain the hematocrit at 35% to 45% preductal and postductal values.
• ECMO for patients who are unresponsive to Sedation may be necessary to provide comfort and
above therapeutic measures with an OI greater decrease the oxygen consumption caused by agitation
than 40. in hypoxemic neonates, though its use has not been
tested in randomized trials (5). Opioid analgesics such
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Table 6-1 Therapies for PPHN Based Box 6-3 Respiratory Alkalosis and PPHN
on Oxygenation Index
Oxygenation
Although hyperventilation (PaCO2 less than
Index Therapy Recommended Settings 35 mm Hg) has the potential to cause pulmonary
vasodilation, this effect is due to the fact it in-
<20 Supplemental Adjust FIO2 for PaO2
creases pH. Unfortunately, hypocarbia and alka-
oxygen 90–120 mm Hg
losis also cause a decrease in cerebral perfusion,
CMV • SIMV which has been associated with hearing loss and
• PEEP >4 cm H2O neurological injury in the follow-up studies of in-
• PIP for volume target fants who survived PPHN (22, 23). Alkalosis also
4–8 mL/kg causes a left shift of the oxyhemoglobin dissocia-
• RR to maintain PaCO2 tion curve, which means that oxygen molecules
35–45 mm Hg are more readily affixed to hemoglobin (Hb).
(20–60 breaths/min) This impedes the unloading of oxygen from Hb
HFOV • Bias flow 10–20 LPM at the capillaries, which can potentially decrease
• Hz 10–12 oxygen delivery to the tissues and cause tissue
• TI 33% hypoxia (44). The development of specific pul-
• Paw 2–3 cm H2O monary vasodilators has made the practice of
greater than CMV hyperventilation-induced alkalosis unnecessary,
• P for visible chest and it is no longer a supported practice.
wiggle
HFJV • Rate 420 (may need
to lower; change in
60 breaths/min
cared for in institutions that have immediate avail-
increments)
ability of personnel, including physicians, nurses, and
• TI 0.02 seconds
RTs, who are qualified to use multiple modes of ven-
• Optimal PEEP (see
tilation and rescue therapies. The radiological and
Chapter 4 for proce-
laboratory support required to manage the broad
dure); > 5 cm H2O
range of needs of these infants is also essential.
• PIP for normocapnia;
begin with same as High-Frequency Ventilation
CMV
High peak pressures and FIO2 on CMV increase the
>20 iNO Starting dose 20 ppm risk for volutrauma and are often not well tolerated
Wean FIO2 when positive by patients with PPHN. High-frequency ventilation
response seen (HFV) uses small VT values at rapid rates, along
Wean by cutting dose in with an “open lung” strategy to maximize lung in-
half until 5 ppm, then flation and oxygenation. Both high-frequency oscil-
discontinue latory ventilation (HFOV) and high-frequency jet
>40 ECMO ventilation (HFJV) can be used to improve oxygena-
tion and ventilation of patients with PPHN who
“fail” CMV. Significantly more published data are
available on the use of HFOV specifically for this pa-
as morphine or fentanyl may be administered if tient population, and thus the discussion here will
patient-ventilator asynchrony is a cause of hypoxemia. focus on HFOV. Using the same mean airway pres-
Prolonged use of opioids can cause hypotension, sures (Paw), HFOV has been shown to improve oxy-
edema, and poor lung function. If asynchronous genation faster than CMV without an increase in
breathing continues without an identifiable cause, complications (26). This is most likely due to the
neuromuscular blockers can be used, but their use has early prioritization of lung recruitment during
been linked to an increased incidence of hearing HFOV (27). Compared with CMV, HFV improves
impairment in survivors of PPHN (24). The use of gas exchange, promotes more uniform lung infla-
sedation and paralytics should be reserved for patients tion, decreases air leaks, and reduces inflammatory
who are unable to be effectively ventilated and oxy- mediators in the lung (28). The effective use of in-
genated without them, and their use should be limited haled pulmonary vasodilators, such as inhaled nitric
to less than 48 hours (5, 25). It is critical that infants oxide (iNO), requires adequate lung inflation to op-
with hypoxic respiratory failure for whom conven- timize alveolar drug delivery. HFOV causes safe and
tional ventilator therapy fails or is predicted to fail be effective alveolar recruitment and has been shown to
2831_Ch06_135-164 13/03/14 3:25 PM Page 142
improve the response to iNO and decrease the risk of disease. It is most useful for patients who have sur-
death or need for ECMO in infants with PPHN and factant deficiency or inactivation. It has not been
parenchymal lung disease (29). Infants with more se- shown to improve outcomes for patients with id-
vere PPHN will more frequently require HFOV to iopathic PPHN, but it has been shown to improve
improve ventilation; if this is used correctly, it is very oxygenation and decrease the need for ECMO when
effective. In fact, in one study, 23% of patients recov- parenchymal lung disease was present, such as with
ered from PPHN using HFOV, without requiring sepsis or MAS (31–33). The use of surfactant in
iNO (29). Some centers use HFV as an initial venti- PPHN has increased over recent years, with nearly
lation strategy for patients with PPHN, though there 80% of neonates with moderate-to-severe respiratory
is no clear evidence that prophylactic HFV is better failure currently receiving this therapy (33, 34).
than other modes of ventilation.
The goals of therapy when using HFOV to treat Cardiac Support
PPHN are to rapidly recruit and stabilize alveoli using Reversal of right-to-left shunting through the PDA
Paw, with amplitude (ΔP) providing visible chest wall requires a reduction in pulmonary artery pressure
movement (known as “chest wiggle factor”) to clear and maintaining systemic blood pressure. Cardiac
PaCO2, and adjusting FIO2 to maintain normoxemia function can be supported in severely affected pa-
after alveolar recruitment. Recommended initial set- tients by using inotropes such as dopamine, dobut-
tings are as follows: amine, and epinephrine, which will increase cardiac
• Bias flow 10 to 20 LPM output by increasing heart rate and improving car-
• 10 to 12 Hz diac contractility (35). Norepinephrine has been
• Inspiratory time 33% shown to increase systemic pressure and oxygena-
• Paw 2 to 3 cm H2O above that on CMV (29) tion in neonates who have PPHN (5). Adequate vas-
• ΔP for visible chest wiggle (30) cular volume should be maintained with intravenous
fluids (3), and transfusion of packed red blood cells
During HFV, minute ventilation is calculated using is commonly required to keep hematocrit at 35% to
the formula: f × VT2 ; small changes in delivered vol- 45%, to replace blood lost from sampling and to
ume affect large changes in PaCO2. Ventilation is optimize tissue oxygen delivery.
therefore managed primarily by changing ΔP—
increasing it to remove more PaCO2 and decreasing Pulmonary Vasodilators
it to increase PaCO2. In HFOV, the ΔP setting is
changed directly; during HFJV the PIP setting is ad- When supplemental oxygen and acid-base stabiliza-
justed. If maximum ΔP is unable to sufficiently im- tion are not effective in reversing pulmonary hyper-
prove ventilation, reducing the frequency by 1 Hz tension, vasodilators that target the pulmonary
(60 breaths/min with HFJV) will improve alveolar gas circulation should be administered. The ideal pul-
exchange and increase delivered VT. There are two monary vasodilator would be delivered directly to
reasons for this: the pulmonary vasculature, cause immediate vasodi-
lation, and work selectively on the pulmonary sys-
1. Lower rates allow for more relative time for tem without systemic effect. The most frequently
exhalation, which will allow for better CO2 used pulmonary vasodilator for neonates is iNO,
clearance. which has a short half-life and is administered by
2. Pressure attenuation is less during lower HFV inhalation, making it very selective to the pulmonary
rates; this means that more of the set pressure system. Other vasodilators that have been used for
will reach the alveoli, which creates a higher PPHN include sildenafil, prostacyclin, milrinone,
pressure gradient between inspiration and exha- and magnesium sulfate. Improved methods of in-
lation (ΔP) and more gas exchange per breath haled delivery to selectively target the pulmonary
cycle. circulation are under development. Treatments for
pulmonary hypertension under investigation include
Oxygenation is managed using Paw to recruit and
therapies based on combined mechanisms of action
stabilize alveoli, and the effectiveness of the current
that can be administered by inhalation (36).
Paw should be assessed using both an ABG test and
chest radiograph. If atelectasis is present on radiogra-
phy, then Paw or PEEP should be increased by 1 cm Inhaled Nitric Oxide
H2O until resolved, and FIO2 may need to be increased Nitric oxide is a substance produced by nearly every
transiently until PaO2 is greater than 60 mm Hg. cell and organ in the human body. NO performs
many functions, including vasodilation, platelet in-
Surfactant Therapy hibition, immune regulation, enzyme regulation, and
Exogenous surfactant therapy can be used neurotransmission. Its main use in the medical envi-
to facilitate alveolar expansion in parenchymal lung ronment focuses on the smooth muscle relaxation of
2831_Ch06_135-164 13/03/14 3:25 PM Page 143
Sildenafil
PPHN is associated with high mortality. Currently, Pulmonary Hypertensive Crisis
the therapeutic mainstay for PPHN is assisted ven- A pulmonary hypertensive crisis is characterized by
tilation and administration of iNO. However, NO is a rapid increase in PVR, which results when the
costly and may not be appropriate in resource-poor pulmonary artery pressure exceeds systemic blood
settings. The evidence of high concentrations of pressure and right heart failure ensues. Several risk
phosphodiesterase (PDE) in the pulmonary vascula- factors may contribute to a pulmonary hypertensive
ture during PPHN has led to the appeal of PDE crisis:
inhibitors such as sildenafil (49). Sildenafil was in-
troduced into clinical use for erectile dysfunction, • Hypoxemia
but it was tested in adults with primary pulmonary • Hypotension
hypertension and demonstrated efficacy and safety • Hypoventilation
of oral dosing (5). Fetal lamb models showed a sim- • Inadequate preload of the right ventricle
ilar pathological mechanism of increased expression • Noxious stimulation
of PDE that contributes to impaired vasodilation The management of a pulmonary hypertensive
(50). Sildenafil has been shown to decrease pulmonary crisis consists of eliminating noxious stimuli that
artery pressure and prevent rebound pulmonary cause the increase of PVR, administering a pul-
hypertension after iNO withdrawal in children with monary vasodilator, providing adequate preload,
congenital heart defects (51). and supporting cardiac output. Treatment includes
A significant improvement in oxygenation oc- the following:
curred in the sildenafil-treated neonates with PPHN
6 to 12 hours after the first dose, without evidence • Immediate administration of 1.0 FIO2
of systemic hypotension (52). Oral sildenafil may be • Correction of acidosis
particularly useful for neonates with PPHN who are • Increase in the depth of sedation or anesthesia
not responsive to iNO, who are experiencing re- using fentanyl
bound hypoxemia after withdrawal of iNO (54), or • Administration of pulmonary vasodilators
who are in low-resource or other environments • Support of cardiac output with inotropes
where iNO is not available. The dosing for neonates
and children is not yet clear, but oral dosage ranges
from 0.3 to 1 mg/kg/dose every 6 to 8 hours (54), ■ ■ You arrive for a shift the following night. BB
with a higher 3-mg/kg dose being used in another Porter is now on HFOV, with Paw of 18 cm H2O,
study to treat patients without access to iNO (55). 9 Hz, ΔP of 40 mm Hg, and FIO2 of 1.0; iNO is now
Other pulmonary vasodilators have been suggested at 40 ppm. Umbilical ABG values on these settings are
for use in PPHN, but their safety and efficacy have pH 7.28, PaCO2 65 of mm Hg, HCO2 of 30.1 mEq/L,
not yet been validated (Evidence in Practice 6-1). PaO2 of 35 mm Hg, and MetHb of 3%. OI is now 51.
2831_Ch06_135-164 13/03/14 3:25 PM Page 145
indicator for escalating the process of moving a gas exchange support (oxygen loading, CO2 removal)
patient to ECMO prior to this irreversible point. in venous blood before it reaches the right ventricle.
It is indicated in the management of severe respiratory
Types of Support failure when conventional means of support are un-
Delivery of ECMO can be accomplished with a vari- successful. It does not, however, provide hemody-
ety of cannulation techniques to meet specific needs namic support, because blood is both drained and
for ECMO support. The two cannulation approaches reinfused into the central venous system. Addition-
most commonly used are venoarterial and venove- ally, because both the drainage and reinfusion of the
nous. The decision regarding which type of support blood is in the right atrium, recirculation is common.
to use should be based on the level of cardiac and pul- Recirculation can occur when the blood is inadver-
monary insufficiency and current patient status. A tently siphoned back into the venous drainage cannu-
comparison of the advantages and disadvantages of las after it has already gone through the ECMO
each technique is found in Table 6-2. circuit. The end result of the “arterial” blood mixing
During venoarterial (VA) ECMO support, two with venous blood from the body will invalidate the
large cannulas are inserted by a surgeon, one into the mixed venous oxygen saturation (SvO2), which is a
right internal jugular vein and a second into the right true marker of oxygenation support.
common carotid artery. The cannulas are connected
to the ECMO circuit, creating a cardiopulmonary by-
pass system that parallels the native cardiopulmonary ■ ■ The attending physician has determined that VA
system (Fig. 6-4). Blood is removed from the patient ECLS will be the mode of support. The physician
through the venous cannula, whose tip is placed in the discussed this option with the family, and they have
right atrium. Blood is returned to the aorta via the decided they want “everything done.” The family
right common carotid artery. This essentially bypasses signed the informed consent. The ECLS, ICU, and
the native heart and lungs and will support both the surgical teams have been informed, and the patient
pulmonary and cardiac systems, allowing the heart is being prepped for cannulation.
and lung to rest. It is through this artificial system that
the deoxygenated blood is cycled through the external
ECLS artificial lung, which will provide oxygenation
and ventilation. In addition, the ECMO pump will Initiation
provide cardiac output suitable for the patient. VA Once the decision is made to initiate ECMO, the
ECMO offers the patient hemodynamic support, in team must move quickly because ECMO candidates
addition to respiratory gas exchange. are unstable and critically ill. The patient will need
In venovenous (VV) ECMO support, the surgeon to be moved into a position in which the head is re-
places a double-lumen cannula in the right internal located to the foot of the bed, because the cannulas
jugular vein. This will remove deoxygenated blood in the patient’s neck need to be close to the ECMO
from the right atrium, cycle the blood though an ar- equipment parked at the foot of the bed.
tificial lung oxygenator, and then pump it back into The head is rotated to the left, exposing the
the right atrium where the patient’s native heart will right side of the neck for cannulation. The chest and
be responsible for pumping the blood throughout neck are prepared and draped using sterile technique.
the body. This type of ECMO provides respiratory The RT secures the endotracheal tube (ETT) and
Heat Arterial
Membrane cannula
oxygenator exchanger
Venous
cannula
Bridge
Pump
Figure 6-4 Diagram of VA-ECMO
Bladder System
ventilator circuit to minimize the risk of extubation to the patient cannulas. The patient is now considered
during the bedside surgery. Free-flowing oxygen, “on-ECMO,” and the native function of the patient’s
such as a resuscitation bag, should be removed from heart and lungs can begin to be reduced as the artificial
the bedside to prevent the risk of fire during the system takes over pulmonary and cardiac functions.
cautery process.
• For VV-ECMO support, flow is increased
The intensivist and nursing team will monitor the
slowly over 10 to 15 minutes to a level that is
patient’s vital signs and continue to provide standard
consistent with the needs of the patient, yet has
support therapy while the remaining ECMO team
low recirculation through the cannulas. Maxi-
members prepare for cannulation and ECMO support.
mum flow for a VV-ECMO patient is generally
While the surgeon and the surgical team are can-
150 mL/kg/min.
nulating, the ECMO team will be preparing the
• VA-ECMO support is initiated by slowly in-
ECMO circuit. The ECMO circuit has to be primed
creasing pump flow and allowing the mixing
to connect to the cannulas that the surgeon will be
of the oxygen-rich pump blood with that of the
placing. The first stage in preparing an ECMO cir-
potentially anoxic, depressed patient. Flow is
cuit is to flush through the circuitry and replace air
increased over the next 20 to 30 minutes to a
using carbon dioxide (CO2). CO2 is highly soluble in
support level consistent with the needs of the
blood, decreasing the risk of microbubbles. Crystal-
patient. Maximum flow for a VA-ECMO
loid solution is added and systematically expels CO2
patient is generally 120 mL/kg/min.
as each section of the circuit is primed with fluid.
When the entire circuit is fluid primed, the debub- ECMO Circuit and Equipment
bling process begins, during which any remaining air
Unlike ventilator circuits and other respiratory
bubbles will be evacuated. When the circuit is air-
equipment, there is no standard ECMO setup or
free, the crystalloid may be replaced with packed red
equipment. Each ECMO center may use many dif-
blood cells. The blood-primed circuit is then treated
ferent setups, but all systems will incorporate some
with bicarbonate to adjust for pH, heparin, and cal-
type of equipment described below:
cium chloride. Once the blood is circulating through
the system, a blood sample is drawn from the circuit • ECMO cannulas: Proper cannula size and
to evaluate the pump’s blood gas, sodium, potas- location of the cannulas are crucial for success-
sium, and ionized calcium levels, as well as the clot- ful ECMO support. VA-ECMO cannulas will
ting time of blood in the circuit. These values need have one venous cannula and one arterial can-
to be approximately equal to the patient’s values. nula. As discussed earlier, the venous cannula
The blood is then heated to body temperature and is inserted through the right internal jugular
is ready for connection to the cannulas. vein downward into the right atrium. This can-
Once the cannulas are placed, a chest radiograph is nula traditionally is wire reinforced to prevent
taken to visualize proper position. After the position is kinking and to be visible on a chest radiograph
verified, the surgeon and a member of the ECMO team (Fig. 6-5). In addition, multiple holes will
will make an air-free connection of the ECMO circuit be near the end of the cannula to allow for
2831_Ch06_135-164 13/03/14 3:25 PM Page 148
“rest settings.” These are typically a pressure control membrane to 0.21. The membrane gas ports are
of 20 to 25 cm H2O, RR of 5 to 10 breaths/min, capped to eliminate the artificial lung as a source of
PEEP of 4 to 10 cm H2O, and FIO2 of 0.21 to 0.30. oxygenation and ventilation. The ventilator settings
These settings allow the lungs to heal and let the are increased to a level that would be considered
ECMO circuit provide the pulmonary support. moderate and acceptable. Eventually, the blood en-
Chest radiographs should be taken daily to observe tering and exiting the membrane achieves equilib-
opacification and the healing trend of the lungs, as rium and reflects typical venous values. Blood gases
well as to ensure that the ETT and ECMO cannulas are monitored, and if they are acceptable, then the
remain in optimum position. patient would be prepared for decannulation.
Lung recovery usually occurs over 3 to 5 days, Decannulation is the process of removing the
which can be quantified by improvements in chest ECMO cannulas and ligating the vessels. This is a
radiographs, lung compliance, and gas exchange. surgical procedure, so a sterile field will be created
by the surgical team. Once the ECMO cannulas are
Neurological Support removed, the vessels will be ligated and secured. Any
Sedation is usually required to help provide comfort bleeding will be assessed and controlled. A topical
to the patient and to keep the patient from moving antibiotic will be applied along with a dressing to
too much, which could cause accidental decannula- cover the area.
tion. Paralysis is usually not a part of the maintenance
Complications
of the ECMO patient except in cases of cannulation,
decannulation, or other procedures requiring the Many ECMO cases are without complications; how-
patient to remain motionless. ever, this invasive procedure is not without prob-
Head ultrasounds will be performed routinely to lems. Complications of ECMO can be divided into
rule out intraventricular hemorrhage (IVH). If IVH patient issues and mechanical issues. All patient
is identified, mean arterial blood pressure is reduced, complications may be caused by two physiological
and the ACT range should be lowered. Antifibri- alterations: changes in the blood-surface interaction
nolytic medication should be considered. As with and changes in the blood-flow pattern. Both of these
any complication, the risk versus benefit of continu- variables can have adverse effects on all the organ
ing ECLS should be carefully considered. Because systems. When blood comes into contact with any
ECLS systems are portable, a computed tomogra- foreign surface, thrombus formation and platelet
phy (CT) scan should be considered to provide more consumption will occur. This necessitates the use of
detailed information regarding IVH. heparin and consequently contributes to the bleeding
complications of ECMO.
Weaning ECMO Support and Decannulation IVH is the primary concern for ECMO patients.
Weaning is a term used for slowly decreasing the These patients receive systemic heparin; IVH, as well
ECMO support over time and assessing the patient’s as other physiological issues, could result if not moni-
response to the wean. The amount of time a patient tored closely. In addition, blood-flow changes from the
requires ECMO varies with the diagnosis. The aver- ligation of the right internal jugular vein and the right
age duration for a neonate with PPHN is 4 to 6 days. common carotid artery can create other concerns.
Patients are weaned from ECMO support as toler- Mechanical complications of the ECMO system
ated over several days. This includes lowering the are listed in Box 6-5. It becomes imperative that an
FIO2 of the ECLS blender and the ECMO pump ECMO-trained provider is at the bedside of these pa-
flow to approximately 20 mL/kg/min. Once this level tients at all times to provide emergent troubleshooting
of support is reached, it is necessary to make mod- should the equipment have a mechanical problem.
erate increases in ventilator support to compensate
for the decrease in ECMO support. The patient cir-
cuit is then clamped off, which is known as a clamp ■ ■ BB Porter remains intubated on “lung rest”
trial. During a clamp trial, patients will be without settings. Suctioning is performed cautiously because
ECMO support, and their native cardiorespiratory he is being given anticoagulants. Radiographs are
system can be assessed. While the circuit is clamped, taken each day and reveal that the patient’s lung
blood gases and hemodynamics are monitored. If fields are clear, with bilateral breath sounds. He is
patients can successfully support themselves during not medically paralyzed, but he does receive seda-
this period, it is assumed they will do well when the tion medication as needed for comfort. BB Porter
cannulas are removed permanently. This is called moves appropriately to stimulation and has reactive
“decannulating” the patient. pupils. He is permitted to move slightly; however, he
If patients are on VV-ECMO support, then the is monitored closely so the cannulas are not dis-
weaning trial is slightly different. In VV-ECMO sup- turbed for fear of movement or dislodgement.
port, weaning occurs by lowering the FIO2 to the
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Box 6-5 Complications of ECLS the need for RTs to continue vigorous efforts to
avoid VILI and encourage weaning and extubation
Mechanical Complications of ECLS when possible.
• Clots in circuit
• Cannula problems Meconium Aspiration Syndrome
• Oxygenator failure Meconium is a baby’s first bowel movement, and it
• Air in the circuit usually occurs sometime shortly after delivery. In
• Pump malfunction about 8% to 20% of deliveries, however, meconium
• Heat exchanger malfunction is passed in utero and is identified by meconium-
• Tubing rupture stained amniotic fluid (MSAF) (66–68). Of these
Patient Complications of ECLS fetuses who pass meconium in utero, about 3% to
• Bleeding 5% will aspirate it into their airway before delivery
• Cardiac dysrhythmias (66–68), which can cause varying symptoms of res-
• Dialysis/hemofiltration piratory distress and lung dysfunction. Meconium
• Hemolysis aspiration syndrome (MAS) is defined as respiratory
• Hypertension distress occurring soon after delivery in a meconium-
• Infection stained infant, which is not otherwise explicable and
• Intraventricular hemorrhage is associated with a typical radiographic appearance
• Myocardial stun (69, 70). Wiswell reported 7% of infants born through
• Pneumothorax amniotic-stained fluid developed respiratory distress
• Seizures and 3% developed MAS, with 4.2% having problems
linked to other disorders (68). The reported incidence
of infants with MAS requiring mechanical ventila-
tion is 0.61 per 1,000 live births (71).
Course and Prognosis MAS is a disease process primarily affecting term
and post-term infants. At 34 wG, the incidence of
In the 1980s, one-third of full-term newborns diag-
MSAF is 1.6%; it increases to 30% for infants 42 wG
nosed with PPHN were not expected to survive to
or more (67). Singh reports the rate of MAS in-
hospital discharge (61, 62). The use of high-frequency
creased from 1.1% of infants at 37 wG to 24% of
ventilation, exogenous surfactant, ECMO, and iNO
infants 42 wG or more.
have reduced that number in developed countries to
Factors associated with increased risk of meconium-
around 10% (34). Many of these interventions are ex-
stained fluid and subsequent development of MAS
pensive, however, and may not be readily available in
include the following:
developing countries.
Some causes of PPHN can increase mortality, such • Post-term pregnancy (greater than 42 wG)
as alveolar-capillary dysplasia and mutations in the • Preeclampsia or eclampsia
surfactant protein B gene (5), as well as congenital • Maternal hypertension
diaphragmatic hernias, discussed in Chapter 9. • Maternal diabetes
Most recent studies reporting PPHN morbidities • Intrauterine growth retardation
have identified a significant risk for hearing loss • Abnormal biophysical profile
among survivors, which may not manifest for 18 to • Oligohydramnios
24 months (63). Neurodevelopmental impairment is • Maternal heavy smoking or chronic respiratory
also seen in about 25% of survivors, which may in- or cardiovascular disease
clude cerebral palsy, hearing or vision loss, and low • Abnormal fetal heart rate and nonreassuring
scores on mental or psychomotor developmental in- fetal heart rate tracing
dices (29). In a 2010 study evaluating survivors at • Presence of fetal distress
school age, 24% had respiratory problems, 60% had • Low 5-minute Apgar
abnormal chest radiographs, and 6.4% had some • Ethnicity: Black Americans and Africans have
sensorineural hearing loss. Overall, survivors had av- increased risk when compared with other
erage scores on cognitive and other neurological groups. Those of Pacific Islander and indigenous
tests, but the cohort had a higher-than-expected per- Australian ethnicity are also at increased risk.
centage of IQ scores below 70 points (64). Hoskote • Home births
et al. assessed pulmonary outcomes for infants with
moderate-to-severe PPHN and found them to be Pathophysiology
similar to healthy peers at 1 year of age (65), though Meconium is the by-product or metabolic waste of
they did find some subclinical reductions in airway gestation. It is the first intestinal discharge. Often,
function in their study. This mild reduction supports meconium-stained fluid is explained to parents as
2831_Ch06_135-164 13/03/14 3:25 PM Page 152
Box 6-6 Clinical Symptoms of MAS As with PPHN, preductal and postductal SpO2
monitoring and echocardiogram will confirm, moni-
Abnormal breathing pattern (tachypnea or tor, and evaluate the presence of pulmonary hyperten-
apnea) sion and shunting.
Grunting Initial laboratory evaluation must include the
Nasal flaring following:
Retractions • Complete blood count with differential
Abnormal lung sounds (diminished, unequal, • Test for C-reactive protein, which assesses
rales, rhonchi, wheezing) inflammation
Increased anterior–posterior chest diameter • Blood cultures to evaluate for sepsis, particu-
Chest asymmetry larly if sepsis was the cause of meconium
Cyanosis release
Hypoxemia • Coagulation studies and type and crossmatch
Respiratory acidosis
Any infant presenting with respiratory distress
should be evaluated for sepsis and treated until sepsis
is eliminated as a contributing factor to the respiratory
Infants with MSAF and respiratory distress re- distress. Bacterial sepsis should be suspected in infants
quire monitoring of arterial blood gases, and with meconium-stained fluid. Ongoing evaluation will
an umbilical or peripheral arterial line may be essen- include electrolyte and metabolic evaluations. End-
tial. Blood gas results will typically reveal hypoxemia organ damage must be considered since these infants
and hypercapnia. may have experienced perinatal asphyxia, hypoxemia,
An initial chest radiograph may show patchy and hypoxia.
infiltrates or irregular streaky, linear densities and
consolidation throughout the lung fields. As the dis- Management and Treatment
ease progresses (Fig. 6-7), hyperinflation, atelectasis, The focus of the management in MAS is respiratory
and pneumothorax may be present. The lungs typi- support, and it may vary from supplemental oxygen
cally appear hyperinflated, with flattening of the via nasal cannula to HFOV, iNO, and ECMO, de-
diaphragm, or diffuse patchy densities may alternate pending on the severity of disease. Singh reported
with areas of expansion. Low functional residual ca- the use of the following modalities in the first day
pacity and low lung compliance may be observed after birth to treat more than 7,000 infants over a
as a result of partial or complete atelectasis. In turn, 10-year period: RA (11%); oxygen by hood (33%);
increased functional residual capacity and low lung nasal cannula (10%); continuous positive airway
compliance may be due to hyperinflation (2). pressure (7%); CMV (28%); high-frequency ventila-
tion (8%); surfactant (16%); iNO (6.1%), and extra-
corporeal oxygenation (1.4%). From 2000 to 2006,
iNO and surfactant use increased. High-frequency
ventilation use remained constant at 6% to 9%, and
vasopressors and extracorporeal oxygenation use
decreased. (66)
Care for newborns with MSAF begins in the deliv-
ery room and is adjusted based on the level of hypox-
emia, physical respiratory distress, and respiratory
acidosis. PPHN is treated as needed, using the strate-
gies discussed in the previous section.
tracheal suctioning should only be attempted if the a bulb syringe or a large-bore suction catheter for
infant is unresponsive immediately after birth (75, remaining meconium before proceeding to neonatal
76). Attempting an intubation on a vigorous new- resuscitative efforts with drying, stimulating, reposi-
born may cause vocal cord trauma or initiate a vagal tioning, and administering oxygen or positive-pressure
response caused by the insertion of the laryngoscope. ventilation.
Care must always be taken when considering the To perform an intubation with intent to suction
condition of the newborn, and care should be ad- meconium from the trachea, an appropriate-sized
justed to meet the patient’s needs (70). Although the ETT is used, with a meconium aspirator connected
evidence is not strong regarding suctioning versus to it, which will allow attachment of wall suction and
nonsuctioning, the American Academy of Pediatrics use of the ETT as a large-bore suction device within
(AAP) still recommends endotracheal suctioning the trachea (Fig. 6-8). The infant should be placed
of nonvigorous babies with MSAF (Evidence in in the sniffing position by the nurse, RT, or physi-
Practice 6-2). A nonvigorous baby is defined as hav- cian with a small neck roll under the infant’s shoul-
ing a depressed respiratory effort, poor muscle tone, ders. This will create a straight view of the vocal
and/or heart rate less than 100 bpm. In this instance, cords. The laryngoscope is inserted with the left
it is acceptable to perform an intubation to suction hand by gently opening the infant’s mouth with
the trachea immediately after birth. Suction is limited thumb or finger and then gently sliding the blade
to 5 seconds, and if no meconium is aspirated, no fur- into the mouth. The blade should be inserted only
ther intubations for suctioning are recommended. If far enough to lift the epiglottis up out of the way to
meconium is aspirated and no bradycardia is present, bring the chords into view. Care should be taken to
a judgment is made whether to reintubate and suction not rock back onto the gums, which could cause
a second time. If the heart rate is low, proceed to re- damage and bleeding. Once the cords are visualized,
suscitative efforts with drying, stimulating, reposition- the ETT is inserted down the right side of the mouth,
ing, and administering oxygen or positive-pressure being careful not to obstruct the view, only far
ventilation. enough to watch the glottis markings pass through
A vigorous baby is one with a normal respiratory the vocal cords. If a stylet was used to facilitate in-
effort, normal muscle tone, and heart rate greater tubation, this is removed before the meconium aspi-
than 100 bpm. Such a baby would not be intubated; rator is attached to the end of the ETT. The 15-mm
instead, the mouth and nose may be suctioned with adapter end of the meconium aspirator is attached
to the ETT, and the nipple adapter is attached
to suction tubing connected to a suction regulator.
● Evidence in Practice 6-2 Occlude the thumb port on the meconium aspirator
and withdraw the ETT. Assess the contents of the
Suctioning at Delivery—What Is the aspiration. If there was a large amount of meconium
Evidence? and the infant’s heart rate has not dropped signifi-
The AAP Neonatal Resuscitation Program Steering cantly, try aspirating again. If the infant’s heart rate
Committee in 2010 recommended the following for decreases or not much meconium was aspirated,
newborns with MSAF (74): proceed to resuscitative efforts with drying, stimu-
lating, repositioning, and administering oxygen or
• Obstetricians are not to routinely suction the positive-pressure ventilation.
oropharynx on delivery of the head but before the There was also a time when performing an am-
delivery of the shoulders because a randomized nioinfusion to reduce the incidence of MAS was a
controlled trial demonstrated it to be of no value. common practice. Amnioinfusion is a procedure in
• There is no value to suctioning the trachea of which normal saline or lactated Ringer’s solution is
vigorous babies. placed into the uterus after rupture of the amniotic
• Tracheal suctioning of infants born to mothers sac. The thought is that a dilution of meconium with
with MSAF with poor tone and minimal respiratory warm sterile saline will minimize the severity of
effort is not associated with reductions in the
incidence or mortality of these infants.
• There are no randomized, controlled trials compar-
ing suctioning with nonsuctioning, and therefore
the current practice of performing endotracheal
suctioning of nonvigorous babies with MSAF will
continue.
• If attempted intubation is prolonged and unsuc-
cessful, bag-mask ventilation should be consid-
ered, particularly if there is persistent bradycardia.
Figure 6-8 Meconium Aspirator
2831_Ch06_135-164 13/03/14 3:25 PM Page 155
At least one study compared gastric secretions Most often, infants are hemodynamically stable, but
from healthy term newborns with secretions from they may have hypoproteinemia and/or elevated cen-
newborns with TTN and found that those with TTN tral venous pressure because of an overloaded thoracic
had low lamellar body counts associated with de- lymphatic system. Mild asphyxia may occur, resulting
creased surfactant function. This suggests that some in mild pulmonary capillary leak and myocardial dys-
cases of TTN are associated with surfactant abnor- function with elevated filling pressure.
malities (92), but it is not clear whether this indicates Though not ideal, often the resolution of symp-
surfactant deficiency, dysfunction, or both. Surfac- toms within the time frame is the definitive confir-
tant’s effectiveness can be inhibited by pulmonary mation of a TTN diagnosis. If symptoms of TTN do
edema, and therefore fluid retention may decrease. not resolve within 72 hours or the FIO2 requirement
is greater than 0.40, then the working diagnosis of
Clinical Manifestations TTN has been proven to be incorrect, and additional
Obtaining a comprehensive history is essential to patient evaluation must be done to determine the
identify risk factors for TTN. Infants with TTN usu- cause of respiratory distress.
ally have respiratory distress within 6 hours of birth.
Tachypnea (RR greater than 60 breaths/min), grunt- Management and Treatment
ing, flaring, and retractions are most often noted. Treatment of TTN is supportive, including supple-
A chest radiograph should be obtained (Fig. 6-9) mental oxygen, withholding of enteral feeds, and ad-
and is characterized by the following: ministration of intravenous fluids and antibiotics.
• Diffuse parenchymal infiltrates Infants with TTN are also at risk for hypoglycemia,
• A “wet silhouette” around the heart, or accu- hypothermia, and sepsis, and support for these are
mulation of fluid in the various intralobar given on an as-needed basis.
spaces that indicate increased pulmonary Oxygen therapy is a mainstay of care for
interstitial, alveolar, or pleural water content newborns with TTN. Typical oxygen delivery
• The lungs normally displaying a homogenous includes an oxygen hood or nasal cannula connected
pattern that may be difficult to distinguish to an air-oxygen blender, titrated to maintain SpO2
from respiratory distress syndrome (RDS) 90% to 96% (93). Moderate respiratory distress may
• A coarse interstitial pattern (exhibited in some require NCPAP of 4 to 6 cm H2O to resolve grunting
cases of TTN), similar to pulmonary edema or or retracting. Gradual improvement will be seen
an irregular opacification similar to MAS or over 48 to 72 hours, and an FIO2 of less than 0.40 is
neonatal pneumonia usually sufficient.
• Possible transient slight cardiac enlargement Armangil et al. attempted a trial of salbuta-
mol, an inhaled beta-2 agonist, for the treat-
ment of TTN and found that it improved blood gas
values, decreased RR, and allowed for weaning of
FIO2 when compared with placebo (94).
Supportive care for thermoregulation, fluid, and
nutrition is indicated. Nutritional status should be
supported as needed because nursing or bottle feed-
ing may initially be unsuccessful owing to tachypnea.
Parental nutrition may be included, but continuous
enteral feeds are often tolerated after initial stabiliza-
tion. Hypothermia can be monitored and infants
should be in a neutral thermal environment such as
an incubator or radiant warmer. Evaluation is nec-
essary to rule out sepsis as a cause of respiratory dis-
tress. Additional cardiovascular support is rarely
indicated.
Maternal corticosteroids have been suggested
to accelerate resorption of fetal lung fluid. A single,
2-day course of antenatal steroids 48 hours before
elective cesarean at 37 to 38 weeks appears to im-
prove respiratory morbidity from TTN (95). Its
mechanism of action may be twofold: Antenatal
steroids accelerate lung maturation and surfactant
Figure 6-9 Chest Radiograph of TTN (Courtesy of Jane maturation, and they may also enhance sodium
Benson, MD) channel activity.
2831_Ch06_135-164 13/03/14 3:25 PM Page 159
Course and Prognosis Paw is 11.5 cm H2O. Most current ABG values
are pH of 7.37, PaCO2 of 44 mm Hg, HCO3 of
TTN is a self-limiting disease and rarely causes mor-
25.1 mEq/L, and PaO2 of 68 mm Hg. His HR
tality or long-term morbidity. One study showed
is 125 bpm, BP is 50/30 mm Hg, spontaneous
that babies experiencing TTN have higher risk of
RR is 10 breaths/min, pre-SpO2 is 98%, and
physician-diagnosed preschool asthma, with this as-
post-SpO2 is 93%.
sociation being strongest for male infants (96). There
is also some debate about whether TTN may cause • Do you think this patient is being well managed
pulmonary hypertension because of possible eleva- by his current therapy? Why or why not?
tion in PVR associated with retained lung fluid (97).
The physician would like to change BB Rogers to
This would then follow the same clinical course as
HFOV. If that does not serve to improve ventilation
PPHN, discussed earlier in this chapter.
and oxygenation, he would like to initiate iNO.
• What would you suggest as initial settings for
■ ■ After 5 days on VA-ECMO support, the radiograph HFOV?
is clear, and the patient has bilateral clear breath • Would you recommend iNO for this patient?
sounds. The ECMO pump flow is at 60 mL/kg/min,
and the ECMO blender FIO2 is at 0.30. The attend- ■ Case 2: Baby Girl (BG) Fitzgerald
ing physician decides to wean BB Porter to 20 mL/ You and the delivery room team are called to a
kg/min and prepare for a clamp trial. 41 6/7-wG delivery with MSAF. There is no other
The clamp trial yields an ABG of pH 7.32, PaCO2 significant maternal history.
of 46 mm Hg, PaO2 of 150 mm Hg on ventilator set- • What additional equipment do you need to
tings of SIMV PIP of 24 cm H2O, PEEP of 6 cm H2O, prepare for a delivery through MSAF?
RR of 25 breaths/min, and FIO2 of 0.60 after being
clamped for 1 hour. He has not required hemody- BG Fitzgerald is born and handed to the pediatri-
namic intervention and is stable. The surgeon is cian. She is crying, actively moving her extremities,
called, and BB Porter is decannulated. and has central cyanosis. You also observe meco-
nium staining of her nail beds.
• What is the appropriate delivery room interven-
■■ Critical Thinking Questions: BB Porter tion for BG Fitzgerald?
1. Do you think that HFOV should have been started You place the pulse oximeter on BG Fitzgerald’s
on BB Porter before starting iNO? On what do you right hand, and it reads 55%. At 1 minute, she is
base your decision? still cyanotic, so you begin delivering 0.60 FIO2
2. Should preductal or postductal blood gases be using blow-by oxygen. Her trunk and lips turn
used to monitor BB Porter’s oxygenation status? pink, and at 2 minutes her SpO2 reads 70%. At
What difference do you think it could make in 4 minutes, when you try to remove the blow-by
his care? oxygen, BG Fitzgerald’s lips turn blue.
3. Most research has shown little benefit to increas-
• Where do you think BG Fitzgerald should be?
ing iNO above 20 ppm. Why do you think the
Stay with her mother, go to the newborn
health-care team increased BB Porter’s iNO
nursery, or transfer to the NICU?
setting to 40 ppm?
After admission to the NICU, you place her on an
oxygen hood at 1 and take pre- and post-ductal
SpO2 readings; they are 99% and 87%, respec-
◗● Case Studies and Critical tively. Chest radiograph at admission is significant
for hyperinflation and patchy infiltrates throughout
Thinking Questions the lungs. The physician places an arterial line and
obtains an ABG test value from the umbilicus: pH
■ Case 1: BB Rogers 0f 7.29, PaCO2 of 50 mm Hg, PaO2 of 62 mm Hg.
You are working in a level IIIC NICU and receiving • Do you believe that BG Fitzgerald has PPHN?
shift reports. BB Rogers is a 41-wG newborn, What information leads you to that conclusion?
now 2 days old. He was born via cesarean sec- • What respiratory measures would you suggest?
tion, with Apgar scores of 3 and 6. An echocardio-
gram results in a diagnosis of idiopathic PPHN, ■ Case 3: BB Kirkwood
and he is now being maintained on SIMV, respira- You are called to the newborn nursery to help a
tory rate 35 breaths/min, PIP of 25 cm H2O, PEEP baby in respiratory distress. BB Kirkwood is a
of 6 cm H2O, TI of 0.5 seconds, and FIO2 of 0.90. 37 3/7-wG infant, born 3 hours ago via scheduled
2831_Ch06_135-164 13/03/14 3:25 PM Page 160
cesarean delivery for breech presentation. When The results are pH 7.38, PaCO2 of 34 mm Hg,
you arrive, you note that BB Kirkwood is breathing HCO3 of 19.8 mEq/L, and PaO2 of 60 mm Hg.
65 times a minute, with mild substernal retractions The physician agrees with your recommendation to
and nasal flaring. A pulse oximeter on his right foot begin oxygen therapy, so you start an oxygen
reads 88%. hood at 0.40 FIO2. You auscultate and hear end-
expiratory crackles. A chest radiograph reveals
• What would you like to do?
diffuse parenchymal infiltrates with inflation to eight
You deliver blow-by oxygen and find BB Kirkwood’s ribs posteriorly.
SpO2 rapidly increases to 97%. You transfer him to
• What do you believe is the cause of BB Kirk-
the special care nursery and admit him for respira-
wood’s respiratory distress? How can you
tory distress. Before the nurse begins the admission
definitively diagnose it?
process, you quickly obtain an ABG reading on RA.
Multiple-Choice Questions
1. Which of the following is the best method to 5. After initiation of ECMO, how should ventila-
evaluate oxygenation in a patient with PPHN? tor settings be managed?
a. Oxygenation index a. Patient should be left on the same ventilator
b. SpO2 settings.
c. PaO2 b. PIP and PEEP should be increased until
d. PcO2 patient is stabilized on ECMO.
2. Which of the following are recommended thera- c. Patient should be placed on “lung rest”
pies to decrease PVR in a newborn with severe settings, to include a low RR, FIO2, PIP of
PPHN? 20 cm H2O, and PEEP of 10 cm H2O
I. Oxygen d. Place on CPAP or extubate
II. Paralytic infusion 6. Which of the following are risk factors associ-
III. Hyperventilation ated with developing MSAF?
IV. HFOV VI. Polyhydramnios
V. iNO VII. Post-term pregnancy
a. I, II, IV, V VIII. Preeclampsia
b. I, IV, V IX. Congenital diaphragmatic hernia
c. I, III, IV, V X. Low 5-minute Apgar
d. I, II, III, IV, V a. I, II, III, V
3. What is the first clinical sign that iNO is effective b. II, III, IV, V
in decreasing PVR? c. II, III, V
a. Increase in PaO2 d. I, II, V
b. Echocardiographic evidence of decreased 7. You are called to the delivery of a 41 3/7-wG
pulmonary pressures infant who was noted to have MSAF. The
c. Improved systemic blood pressure baby is delivered and handed to the neonatal
d. A narrowing gradient between preductal and nurse practitioner. The baby is not moving, is
postductal SpO2 not crying, and has blue hands and trunk.
4. You are caring for a 3-day-old baby girl with Based on your assessment, what would be
idiopathic PPHN. She is intubated, on FIO2 1, ideal treatment strategy?
SIMV PIP of 30 cm H2O, PEEP of 8 cm H2O, a. Quickly intubate and suction the airway
RR of 45 breaths/ min (Paw = 16.25 cm H2O). using a meconium aspirator
Her most recent blood gas is pH 7.39, PaCO2 b. Dry, stimulate, and give oxygen
of 40 mm Hg, HCO3 of 23.9 mEq/L, and PaO2 c. Suction the mouth, then nose
40 mm Hg. Based on the patient’s OI, what d. Begin positive-pressure ventilation
would you recommend as the next step in 8. Specify the most common signs and symptoms
therapy for her? of compromise in an infant with MSAF.
a. Increase PIP
b. HFOV
c. iNO
d. ECMO
2831_Ch06_135-164 13/03/14 3:25 PM Page 161
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Section Three
Chapter 7
Pulmonary
Complications
Chapter Outline Key Terms
Chapter Objectives Atelectasis
Key Terms Atelectrauma
Baby Girl (BG) Johnson Chorioamnionitis
Atelectasis Empyema
Pathophysiology Needle decompression
Clinical Manifestations Pericardiocentesis
Management and Treatment Pleural effusion
Course and Prognosis Pneumomediastinum
Pulmonary Interstitial Emphysema Pneumonia
Pathophysiology Pneumopericardium
Clinical Manifestations Pneumothorax
Management and Treatment Pulmonary interstitial emphysema
Course and Prognosis Tamponade
Pneumothorax Tension pneumothorax
Pathophysiology Transillumination
Clinical Manifestations Volutrauma
Management and Treatment
Course and Prognosis
Pneumomediastinum
Pathophysiology
Clinical Manifestations
Management and Treatment
Course and Prognosis
Pneumopericardium
Pathophysiology
Clinical Manifestations
Management and Treatment
Course and Prognosis
Pneumonia
Pathophysiology
Clinical Manifestations
Management and Treatment
Course and Prognosis
Critical Thinking Questions: BG
Johnson
165
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Chapter Objectives
After reading this chapter, you will be able to:
1. List the four signs and symptoms a neonate will display when developing atelectasis.
2. Discuss the indications for nasal continuous positive airway pressure and its benefits to neonatal
patients with atelectasis.
3. Identify two common causes of neonatal pulmonary air leak.
4. List three patient management techniques a respiratory therapist can employ to prevent pulmonary
interstitial emphysema in preterm infants.
5. Differentiate between the radiographic findings of pulmonary interstitial emphysema, pneumothorax,
pneumomediastinum, and pneumopericardium.
6. Choose initial ventilator settings for a patient with pulmonary interstitial emphysema being placed on
high-frequency jet ventilation (HFJV).
7. Discuss the techniques for quick identification and emergency treatment of a tension pneumothorax.
8. List three common microorganisms that cause pneumonia in the neonatal population.
9. Identify one treatment and one preventive measure that neonatal intensive care units can initiate for the
treatment of congenital pneumonia.
Volume (mL/g)
ture 36°C managed in isolette, SpO2 90% on FIO2 2
0.55; RR 30 breaths/min from the mechanical
ventilator. You are called to BG Johnson’s bedside 1.5
Normal
by the nurse because of an increase in the num-
ber of desaturations requiring increases in FIO2. 1
RDS
0.5
tachypnea, in which neonates increase their respira- ■ ■ You arrive at BG Johnson’s bedside to note that
tory rate until gas trapping results, bringing their func- her FIO2 is now set at 0.80 and SpO2 is reading
tional residual capacity (FRC) to normal levels. 89%. You listen to breath sounds and find them to
The condition of patients with atelectasis varies be diminished at bases and more diminished on the
in severity, which will affect the extent of patients’ left side. You also notice that she is displaying sub-
clinical presentation. Clinical signs include the sternal retractions with her spontaneous breaths.
following: After monitoring the exhaled VT read-out for over a
minute, you observe an average of 2.2 mL VT. When
• Cyanosis
you check BG Johnson’s chart, you see that the pre-
• Tachypnea
vious exhaled VT, correlating with the time of the last
• Nasal flaring
ABG measurement, was documented as 4.1 mL.
• Retractions
You call the physician to the bedside and request an
• Grunting
ABG test and a CXR to assist in diagnosing the
• Increasing FIO2 requirements
cause of BG Johnson’s increase in respiratory dis-
• Decreasing trends in mechanical or spontaneous
tress. The physician agrees. ABG value is pH 7.27,
tidal volume despite unchanged peak inspiratory
PaCO2 is 56 mm Hg, PaO2 is 54 mm Hg, and HCO3
pressure (PIP) and peak end expiratory pressure
is 25.3 mEq/L. CXR shows increased areas of opac-
(PEEP)
ity on the left side, consistent with atelectasis.
• Hypercapnia as evidenced by capillary
blood gas (CBG) or arterial blood gas
(ABG) values warning signs. Prevention of atelectasis includes the
• Hypoxemia on ABG following:
• Chest radiographs (CXR) will reveal areas of
increased opacity where alveolar units have col- • Early extubation and withdrawal of invasive
lapsed and are not air-filled (Fig. 7-2). If severe, mechanical ventilation (MV)
the mediastinum may be shifted toward the side • Good airway clearance through adequate
of collapse. If generalized, atelectasis is often suctioning
described as “whiteout” on a radiograph, where • Frequent changes in patient positioning
little inflation is noted. In this case, elevation of • Prophylactic surfactant delivery for
the diaphragm may also be noted. patients with RDS
When delivering surfactant, care must be taken to
Management and Treatment decrease inspiratory pressures during the rapid im-
Prevention and early management of atelectasis is provement of lung compliance, or lung overdisten-
essential to prevent atelectrauma in neonates. It is sion can easily occur. This overdistension can cause
important for respiratory therapists to identify pa- lung tissue injury, known as volutrauma, and pul-
tients at risk for atelectasis and to look for early monary air leaks (discussed later in this chapter). To
prevent overdistension of the alveoli, respiratory
therapists should stay at the patient’s bedside during
the 30 minutes following surfactant delivery and
monitor the patient noninvasively. Changes in tidal
volume, flow volume loops, and pressure volume
loops will denote lung compliance changes and guide
when to decrease inspiratory pressures. Improvement
in SpO2 is a characteristic sign of alveolar recruit-
ment, so decrease FIO2 with improvement in oxy-
genation. Do not wait for blood gas results to make
ventilator setting changes because alveolar damage
is possible before these results become available.
Respiratory therapists can minimize the risk of at-
electrauma in intubated patients by using advanced
patient monitoring tools available on modern neona-
tal ventilators. Using pressure-volume loops will help
therapists recognize when excess pressure is being de-
livered to the lungs without the associated volume.
Trends in exhaled volumes will help therapists assess
Figure 7-2 Chest Radiograph Showing Evidence of ongoing changes in lung compliance and recognize
Right Upper Lobe Atelectasis (Courtesy of Jane Benson, MD) the early formation of atelectasis.
2831_Ch07_165-184 13/03/14 3:24 PM Page 169
or when high respiratory rates are used because ETT adapter is replaced with the LifePort adapter,
there is not enough time for the patients to ex- which is connected to the CV traditionally and to the
hale fully. To avoid auto-PEEP, monitor flow HFJV by a side port on the LifePort adapter. Guide-
loops for cessation of flow at end exhalation and lines for HFJV settings are in Table 7-2.
monitor pressure and volume waveforms for When managing blood gases in HFJV, the follow-
values to return to baseline between breaths. ing guidelines are helpful (15):
• Providing high-frequency ventilation (HFV),
• The main determinant of CO2 clearance is tidal
which is preferred to CMV.
volume (VT). As with HFOV, minute ventilation
• Evidence for high-frequency jet ventilation in
is determined by f × VT2. Therefore, small
this patient population makes it a particu-
changes in VT will have exponentially larger
larly beneficial choice. High-frequency jet ventila-
changes in CO2. Tidal volume is determined by ␦P,
tion (HFJV) uses a transitional flow pattern of gas
or PIP-PEEP. To increase CO2 on blood gas,
delivery, similar to the mechanism panting dogs use
decreasing HFJV PIP is the best option. To
to effectively breathe with very small tidal volumes.
lower CO2, increase HFJV PIP. Changing HFJV
It allows fresh, oxygen-rich gas to travel down the
rate will only have a significant impact on CO2
center of the airways at very high velocity in small
clearance if the reason for hypercapnia is air
bursts, getting downstream of restricted portions
trapping. In this case, decreasing rate will in-
of the airways, reaching the alveoli, and bypassing
crease expiratory time, allowing time for more
damaged portions of the lung without leaking.
effective exhalation and thus decreasing CO2.
Exhalation is passive during HFJV, and carbon
• PEEP is the major determinate of oxygenation
dioxide (CO2) travels by the path of least resistance,
(PO2). Initial setting of PEEP should be to main-
which is against the airway walls in a counter-
tain alveolar stability. Initial PEEP settings with
current helical flow pattern (13) (Fig. 7-5). Passive
HFJV can be 6 cm H2O or higher, which is often
exhalation during HFJV also allows effective venti-
more than CMV. This seems counterintuitive,
lation and oxygenation at lower mean airway pres-
given that one of the initial treatments for PIE is
sures than does HFOV. HFJV rates are about 10
to lower PEEP. The short I-times of HFJV, how-
times faster than CMV, but tidal volumes are about
ever, mean long expiratory times, requiring higher
5 times smaller, making it less likely for volumes to
PEEPs to maintain adequate mean airway pressure
be trapped during exhalation. Improved gas ex-
(Paw) and prevent atelectasis. If atelectasis devel-
change has been shown using HFJV in patients
ops, increasing PEEP and adding an intermittent
with PIE and developing CLD (14).
mandatory ventilation (IMV) rate of 5 to 10
HFJV is achieved in tandem with a conventional breaths/min temporarily will reverse atelectasis.
ventilator. The purpose of the conventional ventila- Returning the IMV rate to 0 breaths/min once
tor is threefold: (1) it provides fresh gas for patient’s atelectasis has resolved will minimize the risk of
spontaneous respiratory effort, (2) it maintains volutrauma. In the absence of atelectasis, FIO2
PEEP settings, and if necessary, (3) it provides “sigh should be increased to improve PO2. Caution must
breaths” to re-expand atelectatic lung units. The be used when adjusting PEEP alone, because it will
HFJV provides PIP, RR, and TI.
Initiating and adjusting settings on the HFJV are
straightforward. To begin, the patient’s standard Table 7-2 High-Frequency Jet Ventilator
Settings For RDS, PIE (14)
Setting Recommendation
O2 in
CO2 out HFJV PIP Initiate approximately the same
as previous conventional ventilation
PIP; adjust for desired PaCO2
HFJV rate 420 bpm (Hertz = 7)
HFJV I-time 0.02 seconds
IMV rate 0 bpm; only activate when recruiting
atelectatic lung units
IMV PIP Adjust to achieve visible chest rise
IMV I-time Approximately 0.4 seconds
PEEP Begin at 7–12 cm H2O, adjust to
optimal PEEP for alveolar stability.
(Raise PEEP until SpO2 stays con-
Figure 7-5 Inspiration and Exhalation With High- stant in CV CPAP mode.)
Frequency Jet Ventilation
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also adjust ␦P, which will change CO2. If CO2 is The management chosen for PIE should be based
adequate, incremental changes of PEEP and PIP on disease progression; thus, a combination of
will maintain at ␦P while still giving the desired strategies specific to an individual patient will pro-
effect for PO2. An example would be to change a vide the best results.
patient with atelectasis from 18/4 to 19/5, maintain-
ing a ␦P of 14 cm H2O and not affecting VT.
• An additional benefit for patient monitoring on
HFJV is servo pressure (16). Servo pressure is ■ ■ Based on BG Johnson’s poor ABG results and
the driving pressure of the HFJV. It automati- cyst-like formation on the left side, you and the
cally regulates how much gas flow is needed to resident agree to initially change her ventilator set-
deliver a set PIP. Servo pressure changes can be tings: decrease PIP and PEEP to19/3, increase RR
an early warning of changes in patient condi- to 45 breaths/min, and decrease TI to 0.30 seconds.
tion. In general, increases in servo pressure mean You will follow up with an ABG test in 30 minutes. If
an increase in lung compliance or improvement you do not see significant improvement as shown
in lung function. A decrease in servo pressure by a pH greater than 7.25, then you agree that
indicates a change such as the following: changing to HFJV is the best option. You have
• Decreased lung compliance (such as with a also placed the patient in the lateral position,
pneumothorax) left side down, to increase ventilation to the
• Worsened lung resistance uninjured lung.
• Obstructed ETT The follow-up ABG results are a pH of 7.22,
• Mucus in the airway, or a need for suctioning PaCO2 of 58 mm Hg, PaO2 of 55 mm Hg, and HCO3
of 23.4. The FIO2 was weaned prior to the ABG test
Servo pressure can be useful in bedside assessment to 0.63, but BG Johnson won’t tolerate an FIO2 any
and management of a patient on HFJV. lower. There was some improvement, so you and the
For patients with unilateral PIE, two therapies resident agree to observe for 2 more hours to watch
have been suggested to promote lung tissue healing. for clinical improvement. After 2 hours there is no
The first therapy is to position the patient laterally, significant change to exhaled VT, SpO2 or FIO2, or
with the affected lung down, which will preferentially blood pressure.
ventilate the superior, or uninjured, lung. The second
and less frequently used therapy is to intubate the
bronchus of the uninjured lung (known as the “con-
tralateral bronchus”) for a period of time, so only
the uninjured lung participates in ventilation (Evi-
dence in Practice 7-1). After discussion with the resident and the
attending physician on call, you agree to start BG
Johnson on HFJV: PIP of 19 cm H2O, RR of
● Evidence in Practice 7-1 420 breaths/min, TI of 0.02 seconds, FIO2 of 0.65.
You will start the PEEP at 4 cm H2O and adjust as
An Old Procedure Revisited needed to find optimal PEEP. You have agreed to
A 2007 clinical case study (17) revisited a less- no rate from the CMV. You begin to gather the
frequently used treatment for PIE: bronchial intuba- equipment for HFJV.
tion. The clinicians selectively left mainstem intubated
a 24 wG infant girl who developed right-sided PIE on Course and Prognosis
day 4 of life that persisted through her second week One study focusing on ELBW infants showed that
of life despite right-side-down positioning and high- the mortality rate of patients with PIE was higher
frequency ventilation with a low MAP strategy. To per- than for those without PIE (37% vs. 6%) (10). Death
form the procedure they turned her head to the right may be caused by circulatory embarrassment, as
with the long bevel of the ETT along the left of the evidenced by hypotension and bradycardia, or by
midtracheal wall (pointing to the normal lung). The impaired gas exchange resulting from air between
ETT was advanced slowly until breath sounds were the alveoli and blood vessels. Another study demon-
no longer heard over the right thorax, and confirma- strated a strong association between patients diag-
tion was made using a CXR. Ventilation MAP and am- nosed with PIE and subsequent development of
plitude were adjusted for unilateral lung ventilation, type 2 chronic lung disease; however, the presence
and the right side was allowed to deflate completely of PIE did not seem to alter outcome regarding
for 24 hours. Before the ETT was returned to its pre- mortality or duration of oxygen dependency (18).
vious position, a follow-up CXR was obtained that In those who are successfully treated, particularly
showed equal lung inflation with no evidence of PIE. those treated with HFV, PIE often resolves within
The patient was extubated to nasal CPAP within 24 to 48 hours. If not treated, PIE can deteriorate
24 hours of PIE resolution. into pneumothorax.
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Pathophysiology
Once the infectious microorganisms reach the lung
tissue, they begin a reaction that causes an outpour-
ing of fluid, inflammatory proteins, and white blood
cells. The alveolar and interstitial spaces are filled
with edema and exudative fluid (fluid with a high
concentration of proteins, cells, or solid debris). This
in turn makes distal lung spaces consolidated, creat-
ing localized areas of low lung compliance that pre-
vent lung inflation and gas exchange. Surfactant
inactivation and dysfunction also occurs, which Figure 7-9 Chest Radiograph of Neonatal Pneumonia
causes pneumonia to mimic the clinical manifesta- (Courtesy of Jane Benson, MD)
tions of RDS in preterm and term neonates. Pneu-
monias can affect localized areas or an entire lobe, a
lung, or diffusely affect both lung regions. lobar or segmental consolidation (Fig. 7-9). GBS pneu-
Pneumonias are classified either as congenital or monia has an appearance similar to that of RDS on
neonatal, differentiated when the infection or pathogen chest radiographs.
is acquired. Congenital pneumonias occur with mater- Mucous culture and sensitivity screening is a use-
nal infection, such as with chorioamnionitis, GBS in- ful diagnostic tool for pneumonia to facilitate iden-
fection, or C. trachomatis. It usually occurs when tification of the infecting microorganism, though it
infected amniotic fluid is aspirated in utero or during is difficult to obtain an uncontaminated tracheal
delivery. Neonatal pneumonia is categorized as early specimen.
onset (within the first 48 hours of life up to 1 week of Management and Treatment
life) or late onset (1 to 3 weeks of life) (31). It can also
be caused by nosocomial infection in the NICU. Prevention of congenital pneumonia is a key initia-
tive in the management of neonatal pneumonias.
Clinical Manifestations There have been some recent movements to decrease
its incidence:
Clinical manifestations of pneumonia are nonspe-
cific, thus pneumonia should be suspected in any • Screening mothers for GBS and administering
neonate with respiratory distress, as classified by prophylactic antibiotics to mothers who are carri-
rapid, noisy, or labored breathing; respiratory rate ers. In 2002, the Centers for Disease Control and
greater than 60 breaths/min; retractions; cough; Prevention, the American College of Obstetri-
and/or grunting (31). Other signs may include the cians, and the American Academy of Pediatrics
following (32): revised the guidelines to prevent early-onset GBS
disease. Recommendations include universal
• Poor reflexes screening of all pregnant women in the United
• Lethargy States for rectovaginal GBS colonization at 35 to
• Hyperthermia (more frequently seen with full- 37 wG and administration of intrapartum anti-
term neonates) or hypothermia (more common biotic prophylaxis to carriers (33).
in preterm neonates) • Administering maternal and neonatal antibiotics
• Abdominal distention as routine management for chorioamnionitis.
Both fever and feeding intolerance seem to occur • Promoting hand hygiene. A 2009 study assessing
in only about half of diagnosed cases of pneumonia a hand hygiene initiative in five NICUs showed a
(31). Pulmonary hemorrhage is commonly associ- decrease in ventilator associated pneumonia of
ated with gram-negative organism pneumonias. 38% after launch of the program (34).
Pleural effusion (fluid between the pleura) or • Promoting vigorous antibiotic treatment of moth-
empyema (pus in the pleural cavity) may occur with ers with rupture of membranes or premature labor
any bacterial pneumonia. between 22 and 26 wG, plus treatment of the in-
CXR will assist in definitive diagnosis of pneumonia fant immediately after delivery prophylactically
and may include nodular or coarse patchy infiltrates, because of frequent underdiagnosis of lung infec-
diffuse haziness or granularity, air bronchograms, and tion during the early neonatal period (35).
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Most management of pneumonia is sup- 2. If you noticed a sharp drop in servo pressure while
portive: oxygen for hypoxemia, ventilation BG Johnson was on HFJV, what might be the
for apnea and hypercapnia, thermoregulation, cause?
and IV fluids and nutritional supplementations 3. If BG Johnson had not had a positive transillumi-
. Antimicrobial therapy should be based on the nation, what should have been the next step in her
organism cultured and its sensitivity. Until sen- management?
sitivity is determined, broad-spectrum antibiotics are 4. How do you think BG Johnson may have presented
often started, usually consisting of a penicillin (ampi- differently if she had developed a simple pneumoth-
cillin) and an aminoglycoside (gentamicin). Exogenous orax instead of a tension pneumothorax?
surfactant delivery has been shown to increase gas ex-
change in GBS pneumonia, but clinically its response
time was slower, and patients required more doses than
did patients with RDS. There seems to be no harm,
however, in implementing surfactant therapy for pneu- ◗● Case Studies and Critical
monia, and it appears to improve respiratory symp-
toms about 70% of the time (36). Thinking Questions
Course and Prognosis ■ Case 1: Baby Boy (BB) Adkinson
The number of neonatal deaths worldwide in 2008 You are an RT in a 400-bed hospital working a
caused solely by pneumonia was 386,000 (36). Infec- shift in the level IIIA NICU. After completing your
tion of amniotic fluid leading to pneumonia was a ventilator rounds, you stop by the bedside of BB
major cause of death in ELBW infants in one study; Adkinson, a 28 wG infant now 1 week old, weigh-
however, in 61% of the cases infection was not diag- ing 1,240 g. He was intubated in the delivery room
nosed until autopsy, and deaths were attributed clin- and received two doses of exogenous surfactant.
ically to RDS or immaturity (34). This suggests that He was extubated on DOL 3 to nasal CPAP and
clinicians may be missing infections in a significant weaned to a 1 LPM nasal cannula 2 days ago. BB
number of premature infants with respiratory dis- Adkinson’s nurse notes that he had had an in-
tress. Pneumonia has also been noted as a cause for crease in the frequency of apneas today that
the development of CLD in near-term infants (37). required stimulation. It does not seem to improve
Prevention tactics have decreased the incidence of with changes in patient positioning. He is currently
congenital and neonatal pneumonia, but it is still a on caffeine citrate for apnea of prematurity,
significant cause of neonatal morbidity and mortal- 5 mg/kg PO. His vital signs are as follows:
ity, even in developed countries. • HR: 143 bpm
• BP: 51/33 mm Hg (MAP 39 mm Hg)
• RR: 76 breaths/min
■ ■ BG Johnson’s chest tube remained in place for • FIO2 requirements noted in the shift report
3 days. After turning off suction and leaving the were 0.35 to 0.45 throughout the day.
chest tube to water seal for 8 hours, the physician
removed the tube, and her pneumothorax did not BB Adkinson is receiving full breast milk feedings
reaccumulate. BG Johnson continued on HFJV for via orogastric tube gavage with no gastric intolerance.
6 days, weaning PIP to 14 cm H2O and FIO2 as tol- The nurse is not sure if he is getting a little worse and
erated until you extubated her to NCPAP plus 5 cm asks for your opinion on his respiratory status.
H2O and FIO2 0.30 on day of life (DOL) 12. You and You note bilaterally decreased breath sounds in
the other RTs continue to monitor her for apneas and BB Adkinson’s bases, grunting, nasal flaring, and
desaturation, and assess for signs of nasal trauma tachypnea (75 to 85 bpm) and note that his FIO2 is
from the NCPAP, but BG Johnson’s respiratory increased on his nasal cannula. You suction the
status has stabilized and she has shown no signs nares without obtaining any mucus. You decide to
of redeveloping atelectasis or air leaks. get a CBG and ask the physician t for a CXR,
which shows radiolucent areas throughout both
lung fields, with the diaphragm at the seventh ribs
posteriorly. CBG results are 7.28/56/25.9, FIO2 is
set at 0.70, and SpO2 is 90%. This morning’s lab-
■■ Critical Thinking Questions: BG Johnson oratory results showed a hemoglobin count of
1. If the initial treatment for BG Johnson’s atelectasis 14 g/dL and hematocrit of 55%.
(increase in PIP and PEEP and repositioning) had
been unsuccessful, what could you have recom- • What do you suspect is BB Adkinson’s
mended to the physician as a next step? primary diagnosis?
• What would you do to reverse the process?
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145 bpm, BP 42/24 (MAP 30) with 20 mcg of stimulates. Palpated HR is 80 bpm, and she has
dopamine, SpO2 86%. The outlying hospital re- still not taken a spontaneous breath. You begin
quested transport of the patient because they bag-mask ventilation (BMV), and after 30 seconds
were unable to manage ventilation and perfusion (approximately 1 minute of life), she still has central
despite maximum available therapy. cyanosis, her HR is 120 bpm, but she still is not
When BB Cunningham is wheeled through the moving or breathing spontaneously.
doors of the NICU, the transport RN expresses his Over the next minute her central cyanosis is
concern that the patient may have developed an gone and her lips and trunk are pink. The physi-
air leak on transport. You quickly connect the cian intubates with a 3.5 ETT, and after auscultat-
patient to the ventilator waiting at the bedside and ing for equal breath sounds, you tape it 8.5 cm at
listen to breath sounds. You hear clear breath the lip. At 5 minutes of life, BG Davis has still not
sounds bilaterally, but heart sounds seem very made any spontaneous movement or respiratory
distant. The SpO2 is 72% on FIO2 1.0, BP is effort, has made no reflexive movement or grimace
30/15 mm Hg (MAP 20 mm Hg), and HR 90 bpm with stimulation, and has acrocyanosis. HR is
despite a 0.1 mL/kg dose of 1:10,000 solution of 130 bpm with bag-tube ventilation. You wrap her
epinephrine upon arrival. A radiology technician is so mom can see her, then place her in an isolette
at the bedside and takes a chest radiograph as and transport her upstairs to the NICU.
BB Cunningham is transferred from the transport
• What do you suspect is causing her poor
isolette to the infant warmer. When the charge RN
APGAR scores and respiratory distress?
finishes connecting the bedside monitor, she notes
that the arterial waveform does not appear to be You arrive at the NICU and the team begins to
working because it is now reading 10/10 mm Hg. admit BG Davis to the unit. Your coworker RT is
You palpate for a brachial pulse but are unable to having difficulty finding an available neonatal venti-
find one. You auscultate again for heart sounds lator and was unable to set one up before you ar-
but hear nothing. rive. You continue manual ventilation with PIP at
approximately 20 and the PEEP dial set at 5 while
• What could be happening right now to BB laboratory values are drawn and the radiographer
Cunningham? shoots films. Results are below:
• What is the most important thing for the
health-care team to do for him right now? • Skin temperature: 35°C
• Rectal temperature: 35.2°C
Case 6: BG Davis • HR: 180 bpm
You are carrying the delivery room pager in an • BP: 42/18 mm Hg (MAP 26)
inner-city hospital and are called to respond to a • ABG values: pH 7.10, PaCO2 45 mm Hg,
precipitous delivery in the emergency room. You, PaO2 82 mm Hg, HCO3 13.8 mEq/L
the pediatrician, and a NICU nurse arrive and are
CXR shows bilateral whiteout, there appears to
given a 30-second report as the baby’s head is
be patchy infiltrates, and diaphragm level is
being delivered. Mom, Ms. Davis, is a 22-year-old
obscured by infiltration but seems to be at the
homeless woman with a history of cocaine use.
sixth ribs posterior
She has had no obstetric care but thinks she is
Your coworker arrives with the ventilator. The
close to term. This is her first live birth, having had
physician is preparing a sterile field to place umbili-
two previous spontaneous abortions. She has had
cal lines in BG Davis and is unable to make rec-
increased vaginal discharge for the last 2 weeks
ommendations for initial ventilator settings by
and came to the emergency department when she
observation, so he asks you to suggest settings
felt she was in hard labor. Her last cocaine use
and relay them to him.
was 2 hours ago, when labor started. You note a
foul smell in the patient room that the emergency • What ventilator settings would you use for this
room nurse attributes to pus in the amniotic fluid. patient?
A baby girl is delivered and given to your team. • What do you suspect is BG Davis’s primary
She appears to be close to term, but you estimate problem? What additional underlying
her to be small for gestational age (SGA), probably respiratory/pulmonary issues may also be
weighing less than 2,000 g. She is covered in foul- contributing factors to her presentation? What
smelling pus; is cyanotic, cool, and limp; and does additional suggestions can you make for
not appear to be making any respiratory effort. patient management?
You clear the airway while the team dries and • Should you administer surfactant?
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Multiple-Choice Questions
1. Which of the following is not a contributing c. Band of air around the chest wall
factor for neonatal atelectasis? d. Large portion of the chest is illuminated
a. Meconium obstruction in the terminal airways 6. Which of the following clinical signs and
b. Lung compression caused by gastric contents symptoms is specific only to tension
c. Low lung compliance pneumothorax?
d. Repeated collapse and re-expansion of alveoli a. Cyanosis/hypoxemia
e. Surfactant deficiency b. Tachypnea
2. NCPAP provides which of the following c. Bradycardia
patient benefits: d. Mediastinal shift to the unaffected
I. Splinting of airways hemithorax
II. Preventing alveolar collapse 7. What is the classic radiographic sign seen in
III. Decreasing lung compliance neonates with pneumomediastinum?
IV. Decreasing airway resistance a. Halo sign
a. I, II b. Spinnaker sign
b. III, IV c. Boot-shaped heart
c. I, II, III d. Ground-glass appearance
d. I, II, IV
8. What is the treatment of cardiac tamponade?
3. Which of the following is the best choice to a. Needle decompression
decrease CO2 on a patient receiving HFJV? b. Transillumination
a. Decrease PIP c. Pericardiocentesis
b. Increase PIP d. Pigtail catheter
c. Increase rate
d. Decrease rate 9. Which of the following is not a microorganism
e. Increase PEEP that commonly causes neonatal pneumonia:
a. Group B streptococcus
4. Which of the following are two causes of PIE b. Chlamydial trachomatis
in neonates? c. Cytomegalovirus
I. Traumatic delivery d. Pseudomonas aueroginosa
II. Excessive mechanical ventilation settings
III. Surfactant deficiency 10. What initiatives can be taken to minimize
IV. Meconium aspiration pneumonia in the neonatal population?
a. I, II a. GBS screening of mothers prior to delivery
b. II, III and prophylactic intrapartum delivery of
c. III, IV antibiotics if she is a carrier
d. II, IV b. Good hand hygiene
c. Antibiotic treatment for mothers with pre-
5. What does a pneumothorax look like during mature prolonged rupture of membranes
transillumination? d. All of the above
a. Small halo of light in the thoracic cavity
b. Air bronchograms illuminated on affected
side of chest
Chapter 8
Multisystem
Complications Elizabeth Cristofalo, MD
Matthew Trojanowski, BA, RRT
185
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Chapter Objectives
After reading this chapter, you will be able to:
1. Recognize some of the signs and symptoms characteristic of a patient developing necrotizing
enterocolitis (NEC).
2. Adjust respiratory support for a patient with medical or surgical NEC to minimize complications.
3. Identify the preventable and unpreventable risk factors for intraventricular hemorrhage (IVH) in a
neonate.
4. Provide ventilatory support to a very preterm infant to minimize the risk of IVH.
5. Describe how a patent ductus arteriosus (PDA) can complicate respiratory management of a premature
infant.
6. Describe the factors that contribute to the development of retinopathy of prematurity (ROP).
7. Implement strategies to improve the quality of oxygen delivery to preterm infants to reduce the inci-
dence of ROP.
8. Recognize the clinical signs and symptoms of a premature infant who is developing sepsis.
■■ Baby Girl (BG) Ray for all children younger than 5 years of age. Only
12% of births in the United States are premature, but
more than two-thirds of the infants who die within
You are a day shift respiratory therapist (RT) in a
the first year of life were born prematurely (3, 4).
45-bed level IIIC neonatal intensive care unit (NICU),
Worldwide, it is the cause of approximately 12% of
and you assume care of BG Ray, a 2-day-old, 25
deaths before age 5, and this proportion is even
2/7 weeks’ gestation (wG) neonate. She is currently
greater in upper-middle and high-income countries,
on a conventional ventilator in synchronized intermit-
where prematurity is responsible for more than 30%
tent mandatory ventilation (SIMV) mode, with the
the deaths in children younger than 5 years (5). Pre-
following settings: peak inspiratory pressure (PIP),
mature babies are susceptible to complications that
20 cm H2O; positive end-expiratory pressure (PEEP),
can result from immaturity and inadequate function
6 cm H2O; respiratory rate (RR), 35 breaths per
of any of their organ systems. Among those who sur-
minute; and fractional concentration of inspired oxy-
vive, the risk of having complications increases as
gen (FIO2) between 88% and 92%. She was diag-
gestational age decreases.
nosed with respiratory distress syndrome (RDS) and
All body systems are affected by prematurity,
received four doses of surfactant in the first 48 hours
leaving them without appropriate protective and
of life; her vent settings were weaned, with FIO2 as
regulatory mechanisms that develop later in preg-
low as 0.25. At 1000, the nurse calls you and the
nancy. Because systems do not function independ-
physician to the bedside because BG Ray had an
ently, variations in ventilation and oxygenation can
acute drop in her blood pressure. You head to the
predispose premature infants to complications in
bedside to assess her breath sounds and chest
other organ systems, and problems with other organ
movement and to check the ventilator.
systems can adversely affect the respiratory system.
Respiratory distress and premature lung develop-
ment are only the beginning of potential system
problems. The gastrointestinal system is not pre-
B
ecause of improvements in perinatal and pared to digest food until later in fetal development;
neonatal care, including important advances the brain has not completely developed; fetal circu-
in respiratory management, the rate of sur- lation may not make the transition smoothly; and
vival of premature infants has increased over the last the eyes are susceptible to injury. Premature infants
few decades, and the lower limit of gestational age are more likely to have injuries to the intestines, the
that is considered viable has decreased. Extremely brain, and retinas, as well as sepsis and a patent duc-
premature infants who survive resuscitation and tus arteriosus (PDA), which is necessary in utero,
proceed to the NICU require highly specialized and but results in complications if it persists after deliv-
coordinated care for months. The risk of mortality ery. In some cases, these complications can impact
during this period varies for each infant and depends the effectiveness of the pulmonary system; other
on gestational age and birth weight, which is highly times, respiratory management can generate or ex-
associated with their risk of developing complica- acerbate complications with other body systems.
tions of prematurity (1, 2). Prematurity is one of the Specifically, necrotizing enterocolitis (NEC) and
most common causes of death during infancy and PDA may make ventilation more challenging for the
2831_Ch08_185-212 13/03/14 3:23 PM Page 187
Premature infants are at risk for developing IVH changes can include sepsis, PDA with shunting, ad-
because of the anatomical changes that occur in the renal insufficiency, hypovolemia, and volume expan-
brain prior to term. To support the rapid brain sion. Other factors that cause changes in cerebral
growth that occurs in utero (discussed in Chapter 2), blood flow, independent of systemic blood pressure,
a temporary blood supply called the germinal matrix include anemia and transfusion, hypo- or hyper-
(GM) emerges before 20 wG. This rich vascular bed glycemia, hypo- or hypercarbia, hypoxemia, and aci-
provides support for developing neuroblasts (em- dosis. Positioning of the head can influence cerebral
bryonic cells that will develop into neurons) through blood flow in small preterm infants, and neutral
the second trimester. Involution of the GM begins positioning has been associated with a lower risk of
at approximately 28 wG and is typically complete IVH (11). High intrathoracic pressure (caused by the
by 36 wG. This vascular structure is the primary high ventilator pressure needed for severe lung dis-
source of bleeding in the brains of premature in- ease, or tension pneumothorax) can affect arterial
fants. In addition to being a very rich vascular bed blood flow to the brain by influencing cardiac out-
with significant flow, the GM is a fragile structure. put. Additionally, constant high intrathoracic pres-
Unlike permanent vascular structures, there is no sure can interfere with venous return from the brain,
collagen support around the GM to prevent it from resulting in elevated venous pressure and venous
rupturing from physical injury or increased blood ischemia. Coagulopathy confers additional risk for
flow. It exists temporarily, during a period when, if developing IVH.
a baby is not born prematurely, the impact of me-
chanical forces from outside the brain are absorbed Clinical Manifestations
by the amniotic fluid and blood flow to the brain is Premature infants are at highest risk of developing
regulated by the placenta. Therefore, this support is IVH within the first few days of delivery. It is very
not necessary when pregnancy continues to term. uncommon for a new bleed to appear beyond the
However, when a baby is born prematurely, this first week of life. However, a bleed that occurs within
vascular bed is susceptible to damage by several the first few days can progress over subsequent days
mechanisms, most commonly by rapid changes in and become larger. This can sometimes result in a
cerebral blood flow. more severe intracranial lesion, such as hemorrhagic
In premature infants, several factors can influence venous infarction or progressive posthemorrhagic
cerebral blood flow. The most premature infants have hydrocephalus, which are beyond the scope of this
not yet developed cerebral autoregulation, which text. There is a great deal of variability in the clinical
maintains a constant cerebral blood flow despite presentation of IVH in premature infants, which can
changes in systemic blood pressure. Without the abil- fall into one of three categories, as described by
ity to autoregulate, the vessels in the brain are even Volpe (12):
more susceptible to changes in physiological status
• Catastrophic deterioration: least frequent; sud-
that can alter the cerebral blood flow (Box 8-1). These
den change in the status of the infant, which
can include hypotension, shocky appearance,
need for increased ventilatory support,
Box 8-1 Clinical Factors That Can Alter seizures, acidosis, or anemia
Cerebral Blood Flow • Saltatory syndrome: more gradual change in
neurological status, tone, and spontaneous
Sepsis movements
Patent ductus arteriosus with shunting • Asymptomatic: most frequent; 25% to 50% of
Adrenal insufficiency IVH patients
Systemic blood pressure changes (such as
hypovolemia and volume expansion) Because there are often no symptoms associated
Anemia and transfusion with IVH, it is standard to perform routine cranial
Hypoglycemia ultrasound studies in premature infants who are at
Hyperglycemia the greatest risk, those born at up to 32 to 34 wG.
Hypocarbia Ultrasound can be performed at the bedside without
Hypercarbia moving or disrupting the care of vulnerable prema-
Hypoxemia ture infants. Ultrasound is very sensitive for detect-
Acidosis ing IVH and monitoring evolution of the bleed. The
Head positioning IVH grading systems found in Table 8-1 also de-
High intrathoracic pressure scribe the clinical manifestations found on ultra-
Coagulopathy sound. Figure 8-1 is illustrative of grades I, II, III,
and IV IVH.
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C
Figure 8-1 Ultrasound Images of Intraventricular Hemorrhage
2831_Ch08_185-212 13/03/14 3:23 PM Page 190
E
Figure 8-1—cont’d
mode (26). Research has revealed some unique ● Evidence in Practice 8-1
pathophysiological features of premature infants,
which provide an opportunity to decrease the risk Therapist-Driven Protocols: What Do
of complications in the brain by optimizing venti- They Help?
lator management. It is important to continue to
investigate modes of ventilation that might be par- In 2004, McMaster University Hospital implemented
ticularly well suited to this population and develop an registered respiratory therapist–driven ventilation
guidelines for best practice. Data regarding selec- protocol in its neonatal unit, with the objective of pro-
tion of MV settings in premature infants with RDS viding greater consistency of care, optimal ventilatory
also apply to infants at risk for IVH: support using evidence-based practice, maximal as-
sistance to the health care team in ventilation man-
• Synchronized mode of ventilation agement, minimal ventilation-related morbidity, and
• PIP to allow for pH of 7.25 to 7.35 and PaCO2 decreased time spent on the ventilator. The protocol
of 45 to 55 mm Hg and to keep VT within pre- was provided to premature infants with a birth weight
scribed limits of less than or equal to 1,250 g who were born within
• VT 4 to 7 mL/kg the center. In the first 4 days, the infants were main-
• RR 30 to 60 breaths per minute tained on SIMV with target pH of 7.22 to 7.35, PCO2
• Inspiratory time (TI) 0.3 to 0.4 seconds of 45 to 55 mm Hg, and PaO2 of 45 to 60 mm Hg.
• Positive end-expiratory pressure (PEEP) 4 to After 5 days of MV, the targets were changed to pH
7 cm H2O of 7.20 to 7.40 and PCO2 of 50 to70 mm Hg. MV
Frequent assessment and early extubation can settings included VT, 4 to 5 mL/kg; PIP, 12 to 25 cm
also play a part in improving the incidence of IVH, H2O; pressure support, 5 to 10 cm H2O; PEEP, 4 to
particularly the more severe bleeds. Some early evi- 8 cm H2O; TI, 0.25 to 0.45 seconds; and RR, 5 to
dence has also shown that using therapist-driven 60 breaths per minute. Extubation occurred when
protocols in patients with RDS may significantly FIO2 was less than or equal to 0.30 and Paw was
decrease the risk of IVH in extremely premature less than 7 cm H2O or less than 8 cm H2O for infants
and extremely low birth weight (ELBW) neonates with birth weights less than 1,000 g or greater than
(Evidence in Practice 8-1) (27). 1,000 g, respectively.
It is also important to discuss the role that high- During the study period, 301 patients were venti-
frequency ventilation (HFV) may play in IVH. The lated using this protocol. The incidence of IVH grades
use of HFV in premature neonates has been de- III and IV decreased from 31% to 18%, along with a
scribed in Chapter 4, and selecting settings should be significant decrease in amount of time on the ventila-
based on the same criteria as for those with RDS: tor before extubation.
Pathophysiology
During fetal development, oxygenated blood travels
from the placenta via the umbilical vein, through the
inferior vena cava (IVC), and to the right side of the A Fetal circulation
heart. A portion of this oxygenated blood is sent
through the patent foramen ovale for delivery to the Closed
brain, and the remainder is pumped by the right ven- ductus
tricle through the main pulmonary artery. In adult arteriosus
Aorta
circulation, this blood would continue to travel to the To lungs
alveolar capillary membrane, where gas exchange Pulmonary
would occur. Because the lungs are filled with fluid, artery
gas exchange does not occur here; instead, the blood
from the right ventricle needs to be diverted to pro-
vide oxygen to the rest of the organs. As a result, only
a small fraction of the blood from the pulmonary ar-
tery (<10%) will travel through the lungs to provide
oxygen and nutrients for lung tissue growth. The
PDA provides a low-resistance pathway to the aorta,
To body
and the majority of the blood pumped from the right
ventricle to the pulmonary artery will follow this B Normal circulation
route, delivering oxygen and nutrients from the pla-
centa to the organs and tissues and then returning to Open
the placenta through the umbilical arteries. ductus
arteriosus
Normal Closure of the Ductus Arteriosus
At the time of delivery, fetal circulation must un-
dergo a dramatic transition for babies to survive
without the support of the placenta. With the initial
expansion of the lungs, fluid clears to establish an
area for gas exchange. Both the stretch of the lungs
and the alveolar oxygen signal the pulmonary vessels
to vasodilate, and pulmonary vascular resistance
(PVR) decreases substantially, allowing blood from
the right ventricle to travel preferentially to the pul-
monary arteries and establish gas exchange. If this
transition occurs properly, the blood flow through C Patent ductus arteriosus
the pulmonary system increases by approximately Figure 8-2 Patent Ductus Arteriosus
10-fold, and blood flow through the PDA will de-
crease significantly (Fig. 8-2). The PDA is still open,
which may allow blood to flow from an area of high deoxygenated blood from the right ventricle may be
pressure to one of lower pressure. During this tran- shunted across the PDA. When deoxygenated blood
sition, in the first few hours of life, it is common for flows, or shunts from right to left (pulmonary artery
PVR to fluctuate, which can result in mild, tempo- to aorta), it mixes with oxygenated blood from the
rary desaturations. If PVR increases transiently and aorta, resulting in the delivery of partially oxy-
becomes higher than systemic vascular resistance, genated blood to the body.
2831_Ch08_185-212 13/03/14 3:23 PM Page 195
Additionally, the pulmonary vascular bed has The lungs have unique properties that make them
extra circulating blood volume, causing increased particularly susceptible to edema. First, the pul-
pressure within the pulmonary vessels. This increase monary capillaries tend to be more “leaky,” meaning
in the hydrostatic forces within the pulmonary ves- fluid is more easily absorbed into the interstitial
sels can result in fluid leaking from the capillaries in space. Second, the alveolar epithelium is extremely
the lungs into the interstitium, or pulmonary edema. thin, making it easily permeated. Pulmonary edema
Fluid distribution within the body is frequently results from any factor that causes an increase in net
disrupted during illness, but it follows a consistent filtration pressure subsequently filling the alveoli and
set of rules. Fluid moves either within the blood ves- interstitial space with fluid.
sels (intravascular) or within the interstitial space
(extravascular). Fluid has the potential to diffuse Clinical Manifestations
across the alveolar-capillary membrane. The direc- Premature infants with lung disease such as RDS
tion in which fluid moves and is distributed depends have increased PVR because of hypoxemia and the
upon four complementary forces: capillary pressure, immaturity of the pulmonary vascular bed. The
interstitial fluid pressure, capillary osmotic (oncotic) PDA can become symptomatic after early pul-
pressure, and the interstitial fluid colloid osmotic monary pathology improves and PVR decreases.
(oncotic) pressure (Box 8-2). Symptoms of a PDA usually present by the end of
the first week of life.
• Capillary pressure tends to force fluid out through
The severity of symptoms depends on the degree
the capillary membrane into the interstitial space.
of left-to-right shunting of blood. Vital sign symp-
• Interstitial fluid pressure can be either positive
toms may include the following:
or negative. When positive, it forces fluid into
the capillaries. When negative, it draws fluid • Tachypnea
out into the interstitial space. • Tachycardia
• Capillary osmotic pressure tends to draw fluid • Persistently low SpO2
inward into the capillaries. • Hypotension
• Interstitial osmotic pressure tends to draw fluid • Widened pulse pressure (difference between
outward into the interstitial space. systemic and diastolic blood pressure)
The overall movement of fluid is reflected by the Cardiovascular symptoms include a hyperactive
net filtration pressure. Under normal conditions, net precordium, increased left ventricular impulse,
filtration pressure is slightly positive, so there is a tachycardia from increased left ventricular load, and
normal tendency for fluid to diffuse across the cap- bounding pulses or palpable palmar pulses.
illary membrane into the interstitial space. In healthy Infants with a PDA may have a systolic murmur
conditions, the lymphatic system normally redistrib- that is best heard at the middle- to upper-left ster-
utes this interstitial fluid. When the net filtration nal border. It usually occurs on the third to fourth
exceeds the body’s ability to eliminate the fluid, how- day of life. In 10% to 20% of infants with a PDA,
ever, the result is edema. In the case of pulmonary there will be no murmur (42). The murmur occurs
edema caused by PDA, the increase in pulmonary when the PDA is very wide and there is not much
blood flow due to left-to-right shunting causes an in- turbulent flow. The murmur may sound rough and
crease in capillary pressure, forcing blood into the irregular, or “rocky” in premature infants. As flow
alveolar air space. through the PDA increases, it continues through
both systole and diastole, changing the murmur
from systolic to a continuous murmur, described as
Box 8-2 Movement of Fluid at the Alveolar- a sound similar to machinery running; this “contin-
Capillary Membrane uous machinery” murmur is more common in older
infants.
Forces moving fluid from capillaries to the inter- Respiratory symptoms typically manifest as in-
stitial space: creased work of breathing (WOB), which can be
challenging to distinguish as being cardiac versus
Capillary pressure pulmonary in origin. Respiratory distress is evi-
Interstitial osmotic pressure denced by the following:
Forces moving fluid from the interstitial space • Tachypnea
into the capillaries: • Nasal flaring
Capillary osmotic pressure • Grunting
Interstitial fluid pressure can cause fluid to move in • Substernal or intercostal retractions
either direction. • Auscultation that reveals rales, crackles, or
coarse breath sounds
2831_Ch08_185-212 13/03/14 3:23 PM Page 197
the ductus arteriosus (Fig. 8-3). The lung, vagus nerve, resulting from pulmonary overcirculation. Manage-
and laryngeal nerve are all in close proximity to the ment of pulmonary edema can be challenging. A
surgical site and require careful protection to prevent balance must be struck between reducing extravas-
injury. A chest tube is normally left in place to allow cular volume and maintaining adequate intravascu-
evacuation of any air, blood, or fluid postoperatively. lar volume.
Ligation provides definitive closure but has been as- Continuous positive pressure can be used in the
sociated with many risks, including the following: lung to alleviate capillary leakage, similar to the
technique used to stop bleeding from a laceration.
• Pneumothorax
Applying pressure that opposes the movement of
• Chylothorax
fluid into the interstitial space can help shift that
• Scoliosis
fluid to the intravascular space. This is usually ac-
• Infection
complished through the application of PEEP. PEEP
• Unilateral vocal cord paralysis
provides a positive pressure that opposes the out-
• Diaphragm paralysis
ward movement of fluid. Increasing end-expiratory
• Profound postoperative hypotension
lung volume has been a standard practice in man-
• Increased risk of bronchopulmonary dysplasia
aging pulmonary edema in neonates (51, 52). When
Respiratory Management pulmonary edema manifests, increasing PEEP in an
intubated patient by 1 to 2 cm H2O at a time and
In addition to medications, adjustment of me-
monitoring for positive response is a reasonable
chanical ventilator settings can potentially alleviate
strategy. HFOV has also become a method for man-
respiratory compromise associated with pulmonary
agement of severe and/or hemorrhagic pulmonary
edema. Respiratory complications from PDA are
edema because it is able to safely deliver higher
most often associated with the pulmonary edema
Paws (53). Clinicians must be cautious because the
application of excessive pressure to the lungs can
cause additional complications such as air leaks, as
discussed in the Chapter 7. The constant high in-
trathoracic pressure with HFOV, if delivered in ex-
cess, can compress the heart, which can impede
venous return and decrease preload; this, in turn,
120.59° will decrease cardiac output. The pressure from the
HFOV can also cause external compression of the
pulmonary vasculature, which can contribute to
pulmonary arterial hypertension. When using these
methods to manage pulmonary edema, it is impor-
tant to monitor cardiorespiratory status closely and
follow chest radiographs to evaluate for hyperex-
pansion or pneumothorax, especially if an increase
A in ventilator pressure results in decreased oxygen
saturation or blood pressure.
Edema itself may induce an inflammatory re-
sponse that can deactivate surfactant, which has led
to some interest in the administration of exogenous
surfactant to treat pulmonary edema (54, 55). Al-
though this is not common practice, the practitioner
must appreciate that, in addition to the pulmonary
congestion caused by edema, gas exchange may also
be inhibited by a secondary mechanism of surfactant
deactivation.
Finally, the practitioner must be judicious in the
administration of oxygen. Wide fluctuations in oxy-
gen saturations are a hallmark of a PDA. These fluc-
tuations come from a shift in the direction the blood
is shunted through the PDA. Oxygen is a potent pul-
monary vasodilator. As such, its administration in
B the presence of pulmonary edema can risk significant
Figure 8-3 Chest Radiograph of a Patient Before and pulmonary circulation and subsequent worsening of
After Ligation of Patent Ductus Arteriosus pulmonary edema.
2831_Ch08_185-212 13/03/14 3:23 PM Page 199
■ ■ You suggest to the neonatologist that you of the GI tract. The severity of NEC is variable, and
increase PEEP to 6 cm H2O in an effort to counter- the progression of damage can be unpredictable,
act the pulmonary edema shown on the radiograph. sometimes warranting surgical intervention. In ad-
You decide not to change the PIP, but you are going dition to irreversible damage to the intestines, NEC
to monitor whether the ventilator meets the target can be complicated by acute cardiorespiratory col-
VT. After 2 hours on the new PEEP, FIO2 has de- lapse and death. In survivors of this condition, NEC
creased to 0.30, and breath sounds are equal bilat- and related sequelae can significantly impact long-
erally, with fine rales at bases. term morbidity.
Among the general neonatal population in the
United States, NEC affects fewer than 3 of 1,000
newborns (62–65). However, the incidence varies
Course and Prognosis among medical centers and over time periods in un-
Spontaneous closure of the ductus arteriosus occurs predictable ways. Frequently, cases of NEC within
without sequelae in at least 35% of ELBW infants centers occur in “waves,” similar to epidemics of
and in up to 70% of infants greater than 28 wG (56). infections. However, no predisposing factors (such
However, when patency of the ductus arteriosus as season of the year or infectious agent) are con-
complicates RDS in the preterm infant, mortality sistently present when a series of episodes occurs.
and serious morbidity rates are high (57). PDA that The infants most commonly affected by NEC are
is not responsive to medical therapy is associated very premature with very low birth weight. Re-
with a higher risk of death (58). cently published data from the National Institute
PDA has been related particularly to pulmonary of Child Health and Development (NICHD)
problems. It is believed that a high blood shunt Neonatal Research Network reveal that in partici-
through the ductus is a risk factor for pulmonary pating centers, 11% of infants born at 22 to
hemorrhage (59), and surgical closing of a PDA may 28 weeks’ gestation with birth weights of 400 to
actually increase the expression of proinflammatory 1,500 g developed NEC, and 52% with this compli-
gene markers in the lungs (60). PDA in ventilated cation were managed surgically (66). The reported
infants is also associated with increased risk of mortality rates associated with NEC vary, depend-
chronic lung disease (CLD) (61). ing on the characteristics of the infants affected, the
There are potential complications of medical stage of illness, and comorbidities. Generally, the
PDA therapy, such as renal dysfunction and intes- smallest, most premature infants are least likely to
tinal perforation, and PDA has also been considered survive NEC.
a risk factor for the development of NEC (61).
Pathophysiology
Necrotizing Enterocolitis The etiology of NEC and specific pathophysiological
mechanisms that result in NEC have not been well
characterized. Risk factors that have been associated
with NEC in premature and term infants have pro-
■ ■ BG Ray is now 3 weeks old. She is on a heated,
vided insight into the potential pathophysiological
humidified nasal cannula (HFNC), at 3 LPM and FIO2
mechanisms. It has been proposed that a hypoxic
of 0.21 to 0.30. She has a capillary blood gas drawn
ischemic insult to the GI tract and subsequent reper-
with routine laboratory tests, and the results are as
fusion injury can initiate an inflammatory cascade
follows: pH, 7.31; PcCO2, 54 mm Hg; PcO2, 43 mm
that further compromises gut integrity. The appear-
Hg; and HCO3, 24 mEq/L. Halfway through your
ance of pathology specimens from intestines that
shift, while checking BG Ray’s HFNC, you notice a
have been damaged from NEC appear similar to
small amount of formula around her mouth. You alert
those from adults with ischemic injury to the intes-
the nurse, who informs you that BG Ray has had
tines. When NEC occurs in term infants, there is fre-
some minor regurgitation with feeds, but the amount
quently a characteristic or circumstance that causes
is small and not of concern. The nurse also informs
hypoperfusion to the intestinal tract in the prenatal
you that BG Ray is receiving commercial formula be-
or postnatal period. Some examples include mater-
cause the mother is not interested in breastfeeding.
nal cocaine use and other maternal conditions that
cause insufficient placental blood flow, which also
results in intrauterine growth restriction of the fetus.
Necrotizing enterocolitis (NEC) is a very serious Infants who are born small for gestational age at
complication of prematurity that primarily affects term are at higher risk of developing NEC than are
the gastrointestinal (GI) tract. The process involves infants who have not experienced growth restriction
hypoxic-ischemic and inflammatory damage that in utero, and both may be due to compromised pla-
can result in death of the tissues in almost any region cental blood flow affecting the GI tract. Perinatal
2831_Ch08_185-212 13/03/14 3:23 PM Page 200
and neonatal risk factors in term infants can be gastric aspirates that can be bilious, vomiting, or
linked to compromised blood flow to the GI tract, blood in stools. There are typically abnormalities
as well. For example, perinatal asphyxia and low seen in the abdominal examination in a baby with
5-minute Apgar scores are both consequences of NEC, which can be subtle or profound. These ba-
poor systemic perfusion around the time of delivery, bies can have abdominal distension, hypoactive or
and both are associated with a higher risk of NEC. hyperactive bowel sounds, and a pain response with
Congenital heart disease, umbilical catheters, ex- palpation, such as grimacing or flexing at the hips
change transfusions, and polycythemia with result- and bringing legs toward the abdomen. The skin of
ant intravascular sludging are all risk factors for the abdomen can be reddened (erythema), discol-
inconsistent perfusion to the GI tract and associated ored, or have a bruised appearance from venous
with a greater risk of NEC in term infants. stasis under the skin over the inflammatory site.
In premature infants, NEC is not limited to those NEC can also affect the neurological status of the
with distinct risk factors for hypoxic ischemic injury baby and cause irritability or decreased tone and
to the intestines. However, premature intestines lethargy.
are likely more susceptible to injury from subtle al- Because many of these signs and symptoms are
terations in systemic perfusion. In addition, their nonspecific in premature infants, it is important to
immature host defenses and regulation of inflamma- consider NEC in the differential diagnosis when
tory responses can contribute significantly to the de- checking laboratory test values to further investigate
velopment of NEC. Some risk factors in premature the source of illness. A complete blood count can re-
infants that are associated with decreased intestinal veal anemia and thrombocytopenia. In addition, the
perfusion include the presence of a PDA and treat- white blood cell count can be high, low, or within
ment with indomethacin. There is evidence to sug- normal range. If there is a previous white blood
gest that perfusion to the intestines can be altered cell count for comparison, it can be very helpful in
when a premature infant receives a transfusion for determining whether the count has increased or de-
anemia. In addition, associations have been made creased; either change can accompany NEC. The
between the timing of transfusions in premature in- white blood cell differential can be valuable, as well.
fants and the onset of NEC (67–69). However, these The C-reactive protein (CRP) can be elevated with
studies are retrospective. The temporal association NEC. However, this elevation can occur up to a day
could represent several different factors and should after the clinical onset, or it may not occur at all; a
not lead to the conclusion that transfusions increase normal CRP does not rule out NEC. Metabolic aci-
the risk of NEC in premature infants. dosis can accompany NEC and is likely due to tissue
damage to the intestines, but it can also occur in the
Clinical Manifestations setting of hypoperfusion of the body. When looking
There are numerous signs and symptoms of NEC, at an electrolyte
_
panel, it is useful to check the anion
and the initial presentation can be subtle, with mild gap [Na+ − (Cl + CO2)]. With an elevated anion gap
feeding intolerance, or be quite dramatic. Multiple (greater than 15) in the setting of acidosis (low pH or
body systems are affected by NEC, and symptoms low serum CO2), it is possible that tissue damage has
can initially be broad and nonspecific, such as tem- occurred. Hyponatremia can also be seen with NEC.
perature instability. Respiratory symptoms can in- Laboratory analysis of the patient’s stool frequently
clude tachypnea, increased WOB, hypopnea that reveals the presence of heme (iron-containing portion
can progress to apnea, hypoxia, and the need for in- of hemoglobin), although the blood can often be de-
creased respiratory support. Cardiovascular symp- tected by the naked eye. With the development of
toms may include tachycardia and/or bradycardia sepsis and/or destruction of bowel, disseminated in-
and hypotension. Hypotension with decreased sys- travascular coagulation (DIC) can occur. This process
temic perfusion, referred to as shock, can occur as consumes the factors that clot blood and can mani-
part of the body’s inflammatory response, which fest as oozing or bleeding from any mucosal site or
includes a decrease in vascular tone in addition to into the skin (petechiae). It can be confirmed with
capillary leak; this can be generalized and lead to laboratory values that measure clotting function—
total body edema (anasarca), but it can be worst at prothrombin time (PT) and partial thromboplastin
the site of initial inflammation and cause bowel wall time (PTT)—and there is frequently a decrease in
edema and ascites (fluid in the peritoneal cavity). the number of platelets, which are consumed with the
Poor systemic perfusion can present as pale appear- clotting factors.
ance of the skin with mottling and slow capillary An abdominal radiograph is indicated when there
refill. It can result in compromise to other organs is suspicion of NEC, and it can help to confirm the
as well and present with signs such as decreased diagnosis. NEC is characterized by the appearance
urine output. Presenting signs and symptoms of of air within the intestinal wall, or pneumatosis. The
NEC typically involve the GI system and can in- appearance of pneumatosis on radiography varies
clude feeding intolerance with increased volume of depending on position of the bowel in relation to
2831_Ch08_185-212 13/03/14 3:23 PM Page 201
distended and firm to the touch. You also notice of IV antibiotics and parenteral nutrition during
that she is very tachypneic, and her color is seems bowel rest without enteral feeding.
gray. The nurse tells you that the doctors have Decompression of the bowel is also necessary be-
ordered blood gas, CBC, and CRP tests. The re- cause of poor peristalsis and can be achieved by plac-
sults come back as follows: capillary gas: pH 7.11; ing a nasogastric (NG) or orogastric tube to suction.
PcCO2, 61 mm Hg; PcO2, 34 mm Hg; HCO3, This keeps air and fluid from building up within the
13 mEq/L; CBC: white blood cell count, 50,800; bowel lumen, which puts pressure on the bowel wall.
hemoglobin; 10.1 g/dL; and the CRP, 9.1. The Additionally, close monitoring for surgical compli-
doctors inform you that BG Ray’s abdominal radi- cations is essential. Typically, this includes a physical
ograph shows dilated bowel loops and possible exam and radiograph of the abdomen three to four
free air in the portal vein. times per day to detect increased abdominal girth or
distension, worsening of pneumatosis, or the appear-
ance of free air in the abdomen (pneumoperitoneum).
Management and Treatment Surgical Management
Little progress has been made in developing thera- Approximately 20% to 40% of infants who develop
pies that slow the progression of NEC. Management NEC require surgical intervention, mainly because of
is generally supportive and varies widely depending severe bowel necrosis with intestinal perforation. The
on the degree of severity. It is important to have a degree of intestinal injury that occurs in relation to the
high index of suspicion for NEC in premature in- perforation can vary. A small area of ischemic damage
fants who start to develop any of the symptoms can result in a perforation, or a large portion of the
because early while treating NEC, it is critical to bowel may be necrotic and require surgical excision.
very closely monitor the infant and watching for The extent of bowel removed during surgery has been
potential intestinal complications. The principles of shown to correlate with the likelihood of survival.
management include bowel rest with decompression, There are two surgical approaches for intestinal
parenteral nutrition, broad-spectrum antibiotics, perforation from NEC: exploratory laparotomy and
correction of coagulopathy, replacement of blood primary peritoneal drainage. Until recently, it was
products, and supportive cardiorespiratory therapy. standard for surgeons to perform an exploratory
The simplest cases can be managed with 7 to 10 days laparotomy to identify the site of perforation and
2831_Ch08_185-212 13/03/14 3:23 PM Page 203
Pathophysiology
Vascularization of the retina begins early in fetal de-
Course and Prognosis velopment, around 14 to 18 wG. This process begins
NEC is fatal in about 32% to 39% of diagnosed centrally, at the optic disc, and progresses outward
patients (72, 73); one study found that infants who as the retina differentiates; it is typically completed
die of NEC tend to die quickly, within 7 days of by 40 to 44 wG (81). Like many developmental
diagnosis (74). Factors that are associated with an processes, it is highly regulated and depends on a co-
increased risk of mortality include lower estimated ordinated series of events that occur in response to
gestational age, lower birth weight, lack of prenatal complex signals. This process occurs optimally in the
care, significant lung disease, and vasopressor use at intrauterine environment. When an infant is born
the time of diagnosis. prematurely, the environment changes, and rapid
For premature infants who survive, NEC can sig- adaptations are made to facilitate survival. The char-
nificantly increase the amount of time they are hos- acteristics of the new environment and the survival
pitalized. Patients who require surgical resection responses of the neonate can interfere with retinal
(called “surgical NEC”), have a significantly longer vascularization, which can result in ROP.
hospital stay, higher hospital charges, and greater During the second trimester of gestation, the en-
mortality (75). vironment of the fetus in utero is hypoxic as com-
NEC may slightly increase the risk of neurodevel- pared with the extrauterine environment. As retinal
opmental delay for very preterm infants, but it does differentiation progresses prior to approximately
not seem to negatively impact growth by 2 years of 30 wG, metabolic activity increases, which results
age (76). in a greater degree of hypoxia relative to the metabolic
2831_Ch08_185-212 13/03/14 3:23 PM Page 205
A B
C D
Figure 8-6 Progression of Retinopathy of Prematurity (Courtesy of Michael Repka, MD.)
■■ Critical Thinking Questions: BG Ray You notice that after intubation BB Miller is re-
quiring a FIO2 of 0.80 to 0.90. You request a chest
1. What would be a reasonable PaCO2 range for BG
radiograph, and the doctors at the bedside per-
Ray while you try to minimize the risk of worsening
forming an arterial puncture to take blood for labo-
IVH?
ratory tests provide you with an ABG blood sample.
2. If increasing BG Ray’s PEEP after her NEC diag-
The initial ABG result is pH 6.98; PaCO2, 98 mm
nosis hadn’t improved FRC, what would your next
Hg; PaO2, 51 mm Hg; and HCO3, 12 mEq/L. You
recommendation have been?
review the chest radiograph showing the endotra-
3. Why do you think BG Ray was on a NC at
cheal tube (ETT) is in good position, but BB Miller’s
0.21 FIO2?
lungs are only five ribs expanded and nearly com-
pletely whited out.
• What would you like to do to improve
ventilation?
◗● Case Studies and Critical
You place BB Miller on HFOV: Paw is 14 cm
Thinking Questions H2O; P, 26 cm H2O; and 15 Hz. The subsequent
blood gas result is pH 7.21; PaCO2, 55 mm Hg;
■ Case 1: Baby Boy (BB) Miller PaO2, 51 mm Hg; and HCO3, 12 mEq/L. BB
You are the day-shift RT in a level IIIC NICU. You Miller is currently receiving packed red blood
are called to the bedside of BB Miller, a 27-wG boy, cells. A surgeon has been contacted to review
now 9 days old. He was intubated in the delivery BB Miller’s status and decides BB Miller needs
room for presumed RDS/hyaline membrane dis- exploratory surgery to evaluate the condition of
ease (HMD). Extubated on day of life (DOL) 2 and his intestines. The surgery is performed at bed-
weaned from nasal CPAP to NC 1 LPM on DOL 4, side. Once BB Miller’s abdominal contents are
his feeding via NG tube has increased over the revealed, the surgeons note that much of his
last 2 days. Over the last 3 hours, he had increasing bowel is black. They estimate that BB Miller has
episodes of apnea and bradycardia requiring allevi- lost 30% of his bowel. The surgeons remove
ation with positive-pressure ventilation (PPV) using the necrotic bowel and perform an ileostomy.
a resuscitation bag. You and the neonatologist intu- As BB Miller recovers, you are subsequently
bate for apnea; postintubation chest and abdominal able to wean the HFOV settings and transition
film is pending. Follow-up capillary blood gas after back to conventional ventilation.
intubation is pH 7.20; PCO2, 36 mm Hg; PO2,
43 mm Hg; and HCO3, 13 mEq/L.
You place BB Miller on SIMV; his RR is 35 breaths
per minute, PIP is 18 cm H2O, PEEP is 5 cm H2O,
and FIO2 is 0.47.
• The pediatric resident would like to improve
the pH. What ventilator setting changes would
you recommend to him?
Multiple-Choice Questions
1. You are the only RT working in a 15-bed level 2. Which of the following ventilatory strategies
IIIA NICU. Which of your patients, listed will minimize the risk of IVH in a very preterm
below, is at the highest risk for developing infant?
IVH? a. Minimize hyperoxemia
a. 23 4/7 wG infant, now 4 weeks old b. Maintain mild hypercapnia
b. 25 3/7 wG, newly born, with no prenatal c. Minimize swings in PaCO2
steroid treatment d. Provide mild hyperventilation
c. 27 1/7 wG infant, 2 days old, on NC
d. 34 wG infant, now 2 days old, birth weight
1,750 g
2831_Ch08_185-212 13/03/14 3:23 PM Page 209
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Section Four
Congenital Anomalies
Chapter 9
Abdominal Defects
Chapter Outline Key Terms
Chapter Objectives Atresia
Key Terms Congenital diaphragmatic hernia
Baby Girl (BG) Hendricks (CDH)
Congenital Diaphragmatic Hernia Disruption
Pathophysiology Dysmotility
Clinical Manifestations Echocardiogram
Management and Treatment Epithelialization
Course and Prognosis Excision
Gastroschisis Herniate
Pathophysiology Hypoplasia
Clinical Manifestations Iatrogenic
Management and Treatment Inotropes
Course and Prognosis Malformation
Omphalocele Mesentery
Pathophysiology Necrosis
Clinical Manifestations Gastroschisis
Management and Treatment Omphalocele
Course and Prognosis Perforation
Critical Thinking Questions: BG Polyhydramnios
Hendricks Resection
Case Studies and Critical Thinking Scaphoid abdomen
Questions Tracheal occlusion
Case 1: Baby Boy (BB) Garcia Volvulus
Case 2: BB Hathaway
Case 3: BG McShea
Multiple-Choice Questions
References
213
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Chapter Objectives
After reading this chapter, you will be able to:
1. Describe the fetal growth changes in a patient who develops a diaphragmatic hernia.
2. Describe the delivery room management of a patient with congenital diaphragmatic hernia.
3. Describe the preoperative respiratory management for a patient with a congenital diaphragmatic hernia,
including ventilatory support, treatment for pulmonary hypertension, and extracorporeal membrane
oxygenator (ECMO) therapies.
4. Identify key determinants for when to perform a surgical repair of a congenital diaphragmatic hernia.
5. Describe the most common surgical technique for a diaphragmatic hernia repair.
6. Identify the long-term outcomes for patients with a repaired congenital diaphragmatic hernia.
7. Describe the embryological time frame for when gastroschisis develops.
8. List two potential risk factors for gastroschisis.
9. Define the respiratory therapist’s (RT’s) role during surgical repair of a gastroschisis.
10. Describe the development of omphalocele in utero.
11. Identify three common abnormalities associated with omphalocele.
12. List three methods of repair used for patients with omphalocele.
C
ongenital abdominal defects occur when the
abdominal contents are allowed to develop
Compression
outside of the abdominal cavity. In a congen- of left lung
ital diaphragmatic hernia, the abdominal contents
Abdominal
grow and extend through a hole in the diaphragm and contents in left
occupy space in the thoracic cavity. Ventral wall chest, pushing
defects include several types of malformations, the heart and lungs
most common of which include gastroschisis and to the right side
omphalocele, whereby the intestines and other organs Herniated
are outside of the abdominal wall at delivery. All of diaphragm
these defects require surgical interventions and often
postoperative mechanical ventilation. The respiratory
therapist’s involvement relies heavily on the size and
manifestation of the defect and its impediment on Figure 9-1 Congenital Diaphragmatic Hernia
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increased blood pressure on the left side of the ultrasound. The presence of the liver in the thorax
heart causes a tissue flap to close the foramen (often called “liver up”), regardless of the location of
ovale. With CDH, the pulmonary vasculature the diaphragm opening, is associated with worse out-
may remain constricted, which keeps the comes because it denotes a larger defect and more pul-
pressure in the pulmonary arteries very high. monary dysfunction (6). Measurements of the lungs
This pressure backs into the right side of the and head will be taken to calculate a lung/head ratio,
heart, causing right heart pressures to equal or or LHR. The lower the LHR, the more severe the de-
exceed left heart pressures. This prevents the fect. An LHR of less than 1 is associated with close to
foramen ovale from closing. This can cause a 100% mortality rate, and an LHR greater than 1.4
deoxygenated blood from the right atrium to is associated with an almost 0% mortality rate (6).
mix with oxygenated blood in the left atrium, Polyhydramnios (abnormally high volume of amniotic
potentially causing a lower PaO2 to be ejected fluid) in a patient with CDH is a predictor of poor
from the left ventricle to the aorta and out to clinical outcomes (5). This is thought to be because of
the body, again causing hypoxemia and leading kinking of the esophagus where the stomach has re-
to tissue hypoxia. located to the thorax, which obstructs fetal swallow-
• Malrotation: An incorrect rotation of the intes- ing (7). This can also cause a small fetal stomach
tines during fetal development is called “malro- that’s difficult to see on ultrasound, either in the chest
tation.” The intestines make a very distinct or abdomen.
rotation pattern as they herniate into the umbil- If a CDH is suspected, a fetal MRI may be
ical cord and then return to the peritoneal cav- recommended because it can better visualize all the
ity, beginning at week 5 and continuing until developing organs and more accurately predict the
term. With an open channel into the thorax, severity of the defect. A fetal echocardiogram (ultra-
the intestines will not move into their proper sound of the heart) may also be recommended to
placement in the abdominal cavity. The intes- assess whether the herniation has affected the devel-
tines will also not be correctly affixed to the opment of the heart.
peritoneal cavity by the mesentery (peritoneal
fold that encircles the small intestine and con- Clinical Findings at Delivery
nects it to the posterior abdominal wall). With Most newborns have large, protruding bellies, so one
herniation into the thorax, the intestines have of the most obvious physical findings for a newborn
the ability to float freely, making them more with CDH is a scaphoid abdomen (a hollowed out or
susceptible to compression, twisting, or kinking convex belly; see Fig. 9-2) because the abdominal con-
of the small intestines. Kinking of the intestines tents are in the thorax. CDH should be suspected in
can cause tissue death known as necrotizing a tachypneic newborn with a scaphoid abdomen, but
enterocolitis (see Chapter 8 for more informa- the diagnosis needs to be confirmed by chest and ab-
tion), and without surgical correction, it can dominal radiograph (Fig. 9-3).
cause severe illness and even death. At delivery, newborns with CDH may initially
present with apnea or respiratory insufficiency. They
Clinical Manifestations are not as responsive to traditional interventions in
the delivery room, such as supplemental oxygen or
The first clinical signs of a diaphragmatic hernia are positive-pressure ventilation. Many patients with
usually seen in utero during a prenatal ultrasound. CDH will not transition well to extrauterine life, and
After delivery, patients will exhibit very significant fetal circulation will persist after birth.
signs of respiratory compromise, which will assist in Continuing with newborn assessment, the clini-
dictating their care. cian will not hear lung sounds over both sides of the
chest. Lung sounds will be heard on one side and
Prenatal Findings
bowel sounds on the affected side. Auscultation of
Ultrasound diagnosis of CDH can be made as early
as 15 weeks’ gestation. A diagnosis earlier in gestation
is associated with worse outcomes (5), because an ear-
lier herniation often means a more severe defect and
more pulmonary dysfunction and hypoplasia. The
diagnosis is suspected when the stomach is not seen
where it is supposed to be on ultrasound, and intes-
tines are seen next to the heart. A right-sided CDH
is harder to diagnose in utero because the liver is
the organ that would herniate into the chest, and
liver tissue appears very similar to lung tissue on Figure 9-2 Scaphoid Abdomen
2831_Ch09_213-236 15/03/14 10:47 AM Page 217
of therapy offers the best chance of survival with The next attempted prenatal surgical procedure was
minimal long-term sequelae, and it is imperative for the tracheal occlusion, where a fetus with CDH has his
health-care teams to have a clear management plan or her trachea plugged for a period of time to promote
so that they may maximize outcomes. lung growth. Through clinical and research observa-
tions on animals it was noted that patients with tra-
Prenatal Treatment Options cheal atresia (closure or absence) had lung hyperplasia
There are some general guidelines to assist clinicians (23). If occluding the trachea can cause excessive lung
in prenatal management of CDH, but there is no set tissue growth, perhaps a technique similar to tracheal
standard of care. The first step once definitive diag- atresia could be used to promote lung growth. The the-
nosis has been made is to begin counseling with a ory was that during normal fetal development,
multidisciplinary team consisting of obstetricians, the lungs produce a continuous flow of fluid that exits
pediatric surgeons, and neonatologists. All team the trachea into the amniotic space. In the presence of
members should have experience in the management tracheal obstruction, the lungs grow, and for a fetus
of CDH. Parents should be clearly informed of the with CDH there is gradual return of the herniated in-
potential for a poor outcome for their infant. These testines back into the abdomen. With tracheal occlu-
outcomes include the following: sion, fetuses are given a period of intrauterine tracheal
occlusion, with the use of vascular clips or a balloon,
• Death
sufficient to reverse pulmonary hypoplasia, then the
• Neurological defect
occlusion is reversed when lung growth is adequate
• Pulmonary complications
(20). Although several surgical procedures have been
• Gastrointestinal morbidities
used since the technique was first suggested in 1994, a
• Low quality of life
single surgical technique for tracheal occlusion has not
Optimal prenatal counseling allows parents to yet been established and randomized clinical trials
anticipate and understand the events that are likely
to occur after delivery. It also allows parents the
opportunity for informed decision-making regarding
termination of pregnancy or prenatal therapy. Care ● Evidence in Practice 9-1
of the mother and fetus should be transferred to a
tertiary medical center, and the baby should be
Fetoscope Endoluminal Tracheal
delivered at a facility where ECMO is readily avail- Occlusion (FETO) (24)
able after delivery. Tracheal occlusion has yet to be proven as an effec-
It is difficult to know when prenatal treatment tive treatment for CDH, although it is still offered in a
options should be offered. Prenatal options are most number of hospitals throughout the world. It currently
frequently aimed at those infants least likely to sur- consists of placing and inflating a balloon in utero,
vive without treatment. Some factors used to make which can then be popped when no longer needed.
the determination of likelihood for survival are The detachable balloons were originally designed to
detection of CDH prior to 25 wG, polyhydramnios, treat aneurysms, but were found to be useful for
presence of the stomach in the thorax, small lung- treating CDH. Rather than a major surgical procedure,
to-thorax ratio, and heart hypoplasia (14). Another placement of the balloon in the trachea requires a sin-
sign that can be associated with outcomes is “liver- gle 10-Fr cannula and a 1.2-mm fetal endoscope
down” versus “liver-up” status in CDH. Liver-down under regional anesthesia, and it takes about 20 min-
denotes a liver that is still contained within the utes. LHR was seen to improve when the procedure
abdomen, whereas liver up denotes a liver that has was complete, and studies show promising results,
migrated into the thorax, which is associated with with some survival rates at 77%. Care is being taken
worse outcomes. These have all been reported as with the use of this method, however, because clinical
potential determining factors for fetal surgery. trials have not been done to prove the efficacy of this
The initial prenatal intervention was in utero repair, surgical procedure, although the surgical technique
first attempted in 1984 (21). This was an open fetal has been improved over the last decade or so and
operation requiring surgical incisions in the mother’s risk during the procedure has now been minimized.
abdomen and uterus, and then in the abdomen and Two randomized control trials that have compared
thorax of the fetus. The first successful case using this tracheal occlusion to conventional therapy have
procedure was reported in 1990 (21), and a prospective shown no benefit of surgery over traditional care. It is
randomized study in fetuses with liver-down CDH interesting, however, that the conventional therapy
was started (22). Results showed, however, there was outcomes in these studies have been significantly
no difference in mortality and morbidity with this better than the published retrospective data, and
procedure when compared to postnatal conventional therefore both the surgery and control group have
management, and thus it was not considered favorable better survival rates than that which was predicted.
as a definitive treatment for CDH.
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surgical one” (7). Neither of these physiological facilitated by the selection of excessive pressures,
findings is resolved by repairing the hernia, and which overdistend the functional alveoli and cause
thus the timing of repair is inconsequential to res- parenchymal damage.
olution of lung dysfunction.
The focus of preoperative management now is on Conventional Ventilation
hemodynamic stabilization and respiratory support, The method of mechanical ventilation that has
with avoidance of hypoxemia and acidemia and min- been accepted as standard for CDH patients
imization of iatrogenic lung injury (lung injury was termed “gentle ventilation” in 1985 (29). Many
caused by medical interventions, such as mechanical studies that were conducted and published in the
ventilation). This shift in the focus of care manage- 1990s and early 2000s to assess the effectiveness of
ment to preoperative stabilization and delayed gentle ventilation techniques were summarized in
surgical repair is one of the biggest causes of the a 2007 publication (30). There are no national or
improved CDH survival rate for patients who did international standards for what “gentle ventila-
not undergo fetal intervention (28). tion” entails, but several, more recent studies have
suggested conventional ventilator settings and
Previous Ventilation Strategies clinical targets (2, 11, 13, 15, 17, 19, 20, 31–35).
Prior to the 1990s, the accepted method to treat Therapists should familiarize themselves with
PHTN and hypoxemia in CDH was chemical- and institutional preferences or standards for gentle
ventilator-induced alkalosis (17), with the goal of ventilation.
decreasing right-to-left shunting across the ductus • Peak inspiratory pressure (PIP) limitations seem
arteriosus by decreasing pulmonary vascular to be one of the most accepted parameters to
resistance and pulmonary artery pressures. This monitor and adjust to minimize VILI, although
usually meant hyperventilation and hyperoxy- the maximum PIP may vary from institution to
genation, with goal PaCO2 values at less than institution. Several studies have published
40 mm Hg and PaO2 greater than 100 mm Hg. promising results with a recommended pressure
Postmortem data showed that 91% of patients limit of less than 25 cm H2O (13, 12, 36) or less
with CDH who died had ventilator-induced lung than 26 mm Hg (35). One CDH treatment pro-
injury (VILI) (9), which helped the neonatal com- tocol recommends adjusting PIP to maintain
munity recognize the damage the then-current PaCO2 at 45 to 60 mm Hg (13) and another
model of ventilation caused. VILI can also start a suggests PaCO2 at less than 65 mm Hg (35).
systemic inflammatory response similar to acute Of importance, most studies suggest a
respiratory distress syndrome (ARDS), which can postductal pH greater than 7.2 (12) or
lead to multisystem organ failure (28). VILI can 7.25 (11, 16, 35). One study in particular noted
be caused by several mechanisms, including baro- that the creation of target blood gases was asso-
trauma, volutrauma, and atelectrauma. These are ciated with improved survival of CDH, though
the blood gas targets were not consistent be-
tween study subjects. This suggests that it is the
act of selecting and targeting the blood gas val-
ues that may improve outcomes and not neces-
sarily the specific numerical values chosen (31).
• Peak end expiratory pressure (PEEP) has been
suggested to stay in normal physiological
range (4 to 6 cm H2O) (16), or more
specifically at 5 cm H2O (11).
• Normoxemia has been suggested despite the
presence of PHTN, which often responds
favorably to hyperoxemia. Published data on
oxygen targets suggest the following:
• Preductal PaO2 at greater than 90 mm Hg
(when available) (15)
• Postductal PaO2 at 40 to 80 mm Hg (11)
• Preductal SpO2 at 85% to 95% (13), 90% to
98% (11)
• Postductal SpO2 at greater than 70% (13)
• PEEP at 2 to 5 or less than 5 cm H2O
Figure 9-3 Chest and Abdominal Radiograph Showing • Frequency has been less specifically suggested
a CDH in protocols because it has less of an effect on
2831_Ch09_213-236 15/03/14 10:47 AM Page 221
• Systemic blood pressure greater than 60 mm musculature is contraindicated because of the risk of
Hg consistently over previous 12 hours postoperative bleeding. A prosthetic material, such
• Stable urination of greater than 1 mL/kg/hr as Gortex, can be used for reconstruction and is pre-
over previous 12 hours ferred by most surgeons (Fig. 9-4) (7).
• Tidal volume (VT) greater than 4 mL/kg Closure of the abdominal wall after repair can
with PIP less than or equal to 25 cmH2O result in very high intra-abdominal pressures, and
and PEEP less than 5 cmH2O surgeons may close the skin after surgery without
• Optimal ABG values were reached with closing the abdominal wall musculature; or, a silo
FIO2 less than 0.40 for at least the previ- (described in the following section on gastroschisis)
ous 24 hours. can be used, and the contents of the abdominal
cavity can be reduced into the abdomen over several
Primary Repair Versus Reconstruction days. Air may be seen in the pleural cavity on chest
The most commonly used surgical technique is an radiographs because of lung hypoplasia, but it does
open laparotomy, involving a subcostal (below the not need to be evacuated. Chest tubes are not
rib cage) incision (27), although up to 21% of neona- routinely used, except for active thoracic bleeding or
tal centers performing CDH repair have begun to uncontrolled air leak from barotrauma.
use a minimally invasive surgery laparoscopic repair
(27). In either technique, the abdominal contents are Postoperative Management
excised (removed) from the thoracic cavity, and the Postoperative management of patients with CDH
hernia is closed. If there is enough diaphragm muscle includes stabilization of the pulmonary and cardio-
tissue, the defect can be closed primarily with a non- vascular system, pain management, prevention of
absorbable suture. If there is not enough diaphragm infection, and assessment of gastrointestinal func-
to accomplish a primary repair, reconstruction with tion. Despite reduction of the abdominal contents,
nearby musculature can be accomplished. If there is the pathophysiology of the lungs (lung hypoplasia
likelihood for postoperative ECMO, then nearby and PHTN) remains, and cardiopulmonary manage-
ment will continue with the same goals as presurgical
management.
Weaning of mechanical ventilation is gradual, and
the course will be determined based on clinical data
such as exhaled tidal volumes, blood gas measure-
ments, and spontaneous ventilatory effort. The
removal of the abdominal contents will eradicate the
mechanical compression of the lungs, and some im-
provement in ventilation should be seen. Serial chest
radiographs will be useful in monitoring the growth
of the lungs within the thoracic cavity and the return
of the mediastinum to midline.
Sensorineural hearing loss has been reported in There is an established risk factor for maternal
26% to 49% of CDH survivors (55). Hearing assess- age younger than 20 years (56). This is the only
ments are recommended, but the cause of hearing well-established risk factor. Many of the studies as-
dysfunction is unclear. Contributing factors have in- sessing additional risk factors focus on subsets of the
cluded the duration of mechanical and HFOV, use young maternal age groups, such as the following:
of pancuronium for paralysis, and loop diuretic use.
• Cigarette smoking, which increases carbon
monoxide exposure and is associated with
Gastroschisis increased risk of gastroschisis, particularly
in young mothers
Gastroschisis is an abdominal wall defect character- • Malnourishment in young mothers, which has
ized by protrusion of the intestines through the been associated with increased risk of gas-
abdominal wall not covered by amnion (Fig. 9-5). troschisis, whereas high body mass index (BMI)
It is most commonly found on the right side of the has been associated with a lower risk (60)
umbilicus, occurring there 95% of the time. Occasion- • Recreational drug use in general, and metham-
ally, abdominal contents other than intestines, such phetamines specifically, which have both been
as the liver or gall bladder, can be seen. It is likely that associated as increasing the risk of gastroschi-
the cause of this defect is from a combination of ge- sis (61, 62)
netic and environmental factors. The induction of the • White or Hispanic mothers, who are at higher
defect probably occurs between the end of the third risk than African American mothers (58, 63)
week of gestation and end of the fourth week of ges-
tation (56), with the defect developing between weeks One study showed that infants of young mothers
3 and 8 of gestation. There is a low risk of associated who complained of chest colds and sore throats in the
defects, and only 1.2% of infants with gastroschisis first few weeks of pregnancy were at an increased risk
have chromosomal abnormalities (56), making this of having gastroschisis (61). This suggests that early
defect one that normally occurs in isolation. maternal infection may play a part in development.
The most current incidence rate of gastroschisis
is 3.3 per 10,000 births (56). Unlike most congenital Pathophysiology
defects, the incidence of gastroschisis has increased Gastroschisis occurs when the umbilical cavity
10-fold to 20-fold in the United States in recent within the abdomen fails to form. The expanding gut
years (57). Chabra and colleagues in Washington is not contained in the peritoneal cavity and herni-
State showed an average increase of 10% annually ates, usually to the right of the umbilicus. It is
between 1987 and 2006 (58). It has also been shown unclear why the abdominal wall weakness is usually
to have higher prevalence in regional areas and found on the right side, but in only 5% of cases is the
potentially a higher likelihood of recurrence in fam- herniation found on the left.
ilies (59). It is unclear exactly why this is, but several There is uncertainty about the cause of gastroschi-
risk factors (listed below) have been suggested based sis and its development in utero. There are several
on preliminary and early studies. Survival to repro- theories circulating about the embryological cause of
ductive age is more common, allowing for future this defect, without sufficient evidence to support any
assessment of familial links to this disease. one theory. Traditionally, gastroschisis was thought
of as a disruption in fetal development, meaning it
was abnormally produced after normal development
of the abdominal structures and wall. Now the
assumption is that it is a malformation, meaning it
abnormally occurs during early embryologic devel-
opment (64). It is frequently thought to be vascular
in origin and to be the malfunction or reabsorption
of one of the fetal or embryonic vessels that causes a
weakness in the right side of the abdominal wall, al-
lowing for herniation. The two vessels considered are
the umbilical vein and the yolk sac artery. Not
enough evidence exists, however, to make a definitive
determination of either of these as the cause. Another
hypothesis is that during early embryologic develop-
ment the lateral body-wall folds fail to close at the
midline of the abdomen, leaving a hole where herni-
ation can occur. The size of the hole determines the
Figure 9-5 Gastroschisis extent of the defect.
2831_Ch09_213-236 15/03/14 10:48 AM Page 227
Omphalocele
An omphalocele is a midline defect with the umbilical
cord rising from the middle (Fig. 9-7). The small intes-
tines, liver, and stomach are frequently the herniated
organs. An omphalocele is encapsulated by the peri-
toneal sac, although it is possible for the sac to rupture
and thus expose the viscera. Discussions of omphalo-
Figure 9-6 Using a Spring-Loaded Silo (SLS) to Assist cele and gastroschisis are often paired together because
in Staged Reduction of a Gastroschisis their clinical course neonatally can be similar. How-
ever, their prevalence, causes, pathophysiology, and
outcomes are very different. Omphalocele has a
The silo is sutured to the skin and sits upright
known cause, can be a much more significant defect,
from the abdomen (Fig. 9-6). The silo is then tight-
and has an increased risk for mortality.
ened sequentially to reduce the viscera until they are
Defining the rate of omphalocele is complex
contained in the abdominal cavity. A respiratory
because many neonates with this defect do not make
therapist should be at the bedside during reductions
it to live delivery. The incidence of omphalocele as
in anticipation of respiratory complications because
diagnosed by second trimester ultrasound is 1 per
of pressure on the diaphragm. Once all reductions
1,100 fetuses (70), which drops to approximately 2.5
are complete, closure of the abdominal wall is nec-
out of 10,000 births (56). It occurs within the first
essary. If the wall is not large enough to be sutured
trimester of fetal development and in 76% of cases
closed, then a Tegaderm or mesh patch can be used.
had associated abnormalities (71), with cardiac,
A sutureless closure is also possible, where the defect
cranial, and urogenital defects being most common
is covered with sterile dressings and allowed to heal,
(69). About one-third of fetuses also have trisomy 13
and this method has shown similar outcomes when
(2%), 18 (20%), or 21 (12%) (69). Premature births
compared to traditional closure techniques (67).
occur about 42% of the time, according to one study
Course and Prognosis (70). The incidence of newborns presenting with
omphalocele has decreased in recent years. This is
The survival of infants with gastroschisis to discharge
most likely due to more prenatal diagnoses and
and adulthood is increasingly more common. Mor-
genetic counseling for chromosomal abnormalities
tality rates in the United States from 2003 to 2008
that are incompatible with life (71).
were 3.6% (68). Several factors were associated with
higher mortality, including large bowel resection,
congenital circulatory or pulmonary disease, and
bacterial sepsis (68). The most common complication
was sepsis, which was diagnosed in 31% of patients.
The median length of hospital stay is 35 days, the
majority of which will be spent in intensive care. A
key identifier of morbidity is the number of days the
patient is using mechanical ventilation. This data can
be misleading, however, because time between
reductions, amount of sedative and paralytic, and
ventilator management is not standard between
institutions, or even surgeons, within one institution.
For instance, one surgeon may require heavy
sedation of the patient during the entire course of
reduction, which necessitates intubation and ventil-
ation throughout the several-week course. Another Figure 9-7 Omphalocele
2831_Ch09_213-236 15/03/14 10:48 AM Page 229
■ ■ BG Hendricks was discharged home on day • How would you manage this condition?
67 (9 1/2 weeks old). She was feeding via a gastric • What would be reasonable HFOV settings?
tube and receiving anti-reflux medications. Her family
HFOV is started with a Paw of 15 and a CXR is
brings her into the NICU for a social visit after an
obtained that confirms lung inflation to the eighth
appointment with the gastrointestinal specialist,
rib. Umbilical venous and arterial lines are placed.
when she is about 4 months old. She is still on an
A fentanyl drip is started, and paralytics are admin-
NC 1/2 LPM, and her pulmonologist is concerned
istered. A CXR confirms the team’s suspicion of
that she is aspirating gastric secretions in very small
a left CDH. An echocardiogram is ordered and
quantities when she sleeps; for this reason she will
shows elevated right-sided heart pressures. The
have a sleep study performed in the next month.
first arterial blood gas is 7.36/43/32/20/–0.3 on
Despite these struggles, she is gaining weight and is
100% FIO2. The physician asks you to initiate
now 5.4 kg, has begun to smile spontaneously, and
inhaled nitric oxide as he contacts the nearest
has begun to sleep in 6-hour stretches at night. Her
ECMO referral center for further management.
parents are thrilled with her progress.
• What is an appropriate starting dose for iNO?
What are the team’s options if iNO does not
work?
■■ Critical Thinking Questions: • What is BB Garcia’s oxygen index? Would he
BB Hendricks be considered a candidate for ECMO?
1. Although BG Hendricks was never placed on Case 2: BB Hathaway
HFOV, what clinical signs and key interventions You are preparing for a planned C-section delivery
would make you consider recommending a switch at a level IIIB NICU. Jennifer Hathaway is 16 years
from conventional to high-frequency ventilation? old, and this is her first pregnancy. Her pregnancy
2. What clinical signs would you look for when wean- history is significant for smoking during the first
ing iNO from BG Hendricks that tell you she is trimester, but she quit around week 11 when she
having rebound PHTN? realized she was pregnant. Her parents, with
3. How would you expect her pulmonary status to whom she lives, continue to smoke in the house.
change after her hernia repair? A 21-week ultrasound showed a ventral wall de-
fect consistent with gastroschisis. Jennifer has
met with the neonatologist and a pediatric gastric
surgeon and they discussed the care plan once
the baby is born.
The decision was made at 38 4/7 weeks
◗● Case Studies and Critical gestation to deliver via C-section. A lecithin/
sphingomyelin (L/S) ratio was determined
Thinking Questions to be 2:1.
■ Case 1: Baby Boy (BB) Garcia • What does an L/S ratio of 2:1 indicate?
You are working the night shift in the level IIIB The delivery room team is called to the operat-
NICU. You are called to the emergency room ing room before the first incision is made. The
where a male infant was just born to a 32-year-old neonatology fellow is the leader of the team and
female at 39 weeks’ gestation. Pregnancy, mater- has decided to accept the baby from the obstetri-
nal history, and maternal serologies are unavail- cian upon delivery. She will then step back to
able. Mom does not speak English. The baby was manage the baby. The resident is the second
delivered by the emergency room physician by pre- physician in attendance and will maintain the steril-
cipitous vaginal delivery. Amniotic fluid was clear. ity of the intestines to minimize contamination.
The baby is apneic, pale, and limp, and appears to The NICU nurse will place BB Hathaway in the
have a scaphoid abdomen. The physician asks you bowel bag after the resident and fellow have a
to begin positive-pressure ventilation. Despite ap- quick initial assessment of the defect. She will then
propriate head positioning, placement of a shoul- monitor vital signs. Your job will be the initial steps
der roll, adequate size and seal of the mask, and in resuscitation, to include drying, clearing the air-
good inflation pressures, the physician auscultates way, and stimulation.
diminished breath sounds on the left. Heart sounds The resuscitation goes very smoothly. BB Hath-
are shifted to the right. Heart rate is 80 bpm. away makes initial attempts to breathe within the
• What do you suspect is BB Garcia’s primary first few seconds of life, and by 1 minute is crying
diagnosis? actively. His Apgar score at 1 minute was 7, with
2831_Ch09_213-236 15/03/14 10:48 AM Page 231
Multiple-Choice Questions
1. Which of the following ultrasound findings in a c. Minimize noise at the bedside to prevent
fetus with CDH is not associated with a poor hearing dysfunction
clinical outcome? d. Monitor PHTN via pre- and postductal SpO2
a. Liver in thorax e. All of the above
b. Bowel next to heart 7. At what point in embryologic development
c. LHR of 1 does gastroschisis form?
d. Polyhydramnios a. 3 to 5 weeks’ gestation
2. Determine which of the following should be part b. 3 to 8 weeks’ gestation
of the delivery room management for a newborn c. 6 to 11 weeks’ gestation
who has been diagnosed with a CDH as a fetus? d. By the seventh week of gestation
I. No mask ventilation 8. Which of the following are potential risk fac-
II. Use 1 FIO2 tors for gastroschisis?
III. Create a delivery room plan with team I. Maternal age less than 20 years
IV. Paralytics in the delivery room II. High body mass index
V. Early intubation III. Malnutrition
a. I, II, III IV. Smoking
b. I, II, IV a. I, IV
c. I, II, III, V b. I, II, IV
d. I, II, III, IV, V c. I, III
3. You have a patient who has been diagnosed d. I, III, IV
with PHTN. Ventilator settings are: 9. During a primary closure, the RT should mon-
Mode: SIMV itor the intubated patient for:
PIP: 20 cm H2O a. Signs of wakefulness or pain.
PEEP: 5 cm H2O b. Tachypnea.
Respiratory rate: 35 breaths/min c. High peak pressures or low tidal volumes.
FIO2: 0.80 d. Low PEEP.
The physician would like to increase ventilator 10. Omphalocele develops when portions of the
settings to counteract the effect of PHTN on bowel herniate:
oxygenation and prevent hypoxia. Which of a. To the right of the umbilicus.
the following ventilator changes would you b. Through the diaphragm.
suggest to achieve his goal? c. Into the umbilical cord.
a. Increase PIP to 23 d. To the left of the umbilicus.
b. Increase rate to 40
c. Decrease PEEP to 4 11. Which of the following is not an anomaly asso-
d. Increase FIO2 to 1 ciated with omphalocele?
a. Trisomy 21
4. Which is not a possible presurgical treatment b. Trisomy 13
option for newborns with CDH? c. Trisomy 18
a. Inhaled nitric oxide d. Trisomy 23
b. Tracheal occlusion
c. High-frequency ventilation 12. Which one of these is not a method used to
d. Surfactant replacement therapy assist in closure of an omphalocele defect?
a. Tissue expanders
5. Calculate the oxygen index (OI) for a patient b. Topical treatment for epithelialization
with the following settings and ABG values: c. Primary closure
HFOV: Paw 25 cm H2O, amplitude 30 cm d. Genetic counseling
H2O, Hertz 12, IT 33%
ABG: 7.20/68/44/26.2. On FIO2 0.95 13. The benefits of alveolar surfactant include:
a. 54 I. Lowering surface tension
b. 167 II. Lowering airway resistance
c. 83 III. Preventing alveolar collapse
d. 45 IV. Higher lung compliance
a. I, II
6. Which of the following can RTs do to mini- b. I, III, IV
mize morbidity for CDH patients? c. I, II, III
a. Gentle ventilation d. II, III, IV
b. Avoid hypoxemia
2831_Ch09_213-236 15/03/14 10:48 AM Page 233
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45. Raval MV, Wang X, Reynolds M, Fischer AC. Costs of Birth Defects Res A Clin Mol Teratol. 2010;88(3):178-185.
congenital diaphragmatic hernia repair in the United 64. Feldkamp ML, Carey JC, Sadler TW. Development of
States—extracorporeal membrane oxygenation foots the gastroschisis: review of hypotheses, a novel hypothesis,
bill. J Pediatr Surg. 2011;46:617-624. and implications for research. Am J of Med Genet.
46. Sola JE, Bronson SN, Cheung MC, Ordonez B, Neville 2007;143(A):639-652.
HL, Koniaris LG. Survival disparities in newborns with 65. Lobo JD, Kim AC, Davis RP, et al. No free ride? The hid-
congenital diaphragmatic hernia: a national perspective. den costs of delayed operative management using a spring-
J Pediatr Surg. 2010;45:1336-1342. loaded silo for gastroschisis. J Pediatr Surg. 2010;45:
47. Brownlee EM, Howatson AG, Davis CF, Sabharwal AJ. 1426-1432.
The hidden mortality of congenital diaphragmatic hernia: 66. Jensen AR, Waldhausen JHT, Kim SS. The use of a
a 20-year review. J Pediatr Surg. 2009;44:317-320. spring-loaded silo for gastroschisis: impact on practice pat-
48. Seetharam R, Younger JG, Bartlett RH, Hirschl RB. Fac- terns and outcomes. Arch Surg. 2009;144(6):516-519.
tors associated with survival in infants with congenital 67. Riboh J, Abrajano CT, Garber K, et al. Outcomes of
diaphragmatic hernia requiring extracorporeal membrane sutureless gastroschisis closure. J Pediatr Surg. 2009;44(10):
oxygenation: a report from the Congenital Diaphragmatic 1947-1951.
Hernia Study Group. J Pediatr Surg. 2009:44:1315-1321. 68. Lao OB, Larison C, Garrison MM, Waldhausen JHT,
49. Stevens TP, Chess PR, McConnochie KM, et al. Survival Goldin AB. Outcomes in neonates with gastroschisis in US
in early- and late-term infants with congenital diaphrag- children’s hospitals. Am J Perinatol. 2010;27(1):97-101.
matic hernia treated with extracorporeal membrane oxy- 69. Hwang PJ, Kousseff BG. Omphalocele and gastroschisis:
genation. Pediatrics. 2002;110:590-596. an 18-year review study. Genet Med. 2004;6(4):232-236.
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Chapter 10
237
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Chapter Objectives
After reading this chapter, you will be able to:
1. List several pediatric airway abnormalities that may necessitate a tracheostomy.
2. Manage tracheostomy tube emergencies.
3. Provide airway stabilization for a patient recently diagnosed with choanal atresia.
4. Identify therapies given a newborn with Robin sequence to relieve airway obstruction before surgical
reconstruction.
5. Recommend airway management techniques to minimize the risk of subglottic stenosis for premature
infants requiring intubation and long-term mechanical ventilation.
6. Describe the different forms of tracheoesophageal fistulas.
7. Describe the respiratory management of laryngomalacia.
Clinical Manifestations
Bilateral choanal atresia normally presents at birth,
as the airway obstruction could constitute a medical
emergency. The usual presentation includes obvious
airway obstruction, stridor, and paradoxical cyanosis,
in which infants turn pink when crying as they begin
to breathe through an open mouth and relieve their
own airway obstruction. Unilateral choanal atresia
typically presents later, usually by 5 to 24 months of
age, and will have unilateral nasal obstruction and
persistent nasal discharge (5).
A variety of inexpensive and painless evaluation
methods can be used for preliminary identification
of choanal atresia. For instance, in a tissue test, the
practitioner holds a piece of tissue or wisp of cotton
(easily obtained from a cotton applicator) in front of
each nare: If choanal atresia is present, the tissue
(or cotton wisp) will not move with respiration. Sim-
ilarly, a mirror held under the nares will not fog up Posterior
with respiration, and auscultation with a stethoscope
will not detect the sound of airflow from either nare Figure 10-1 Choanal Atresia (Courtesy of Ellen Deutch MD,
during respiration. A more traditional technique is FACS, FAAP)
to attempt to pass a lubricated, narrow-gauge suc-
tion catheter through each nare; this technique is less
comfortable for the child and can be misleading if openings are able to be created in one surgery, it is
the catheter is thought to have advanced through the known as a primary repair. Some patients may re-
choanae but is actually curled up in the nasophar- quire several procedures, including dilation (stretch-
ynx. Nasal endoscopy at the bedside, using a narrow ing to increase the diameter of the openings). The
fiber optic or rigid telescope or even an otoscope, risks of surgical repair include central nervous sys-
also may be helpful in evaluating choanal atresia. tem (CNS) damage (7) and restenosis or subsequent
Definitive assessment of choanal atresia is by com- closure of the choana, causing recurrence of airway
puted tomography (CT) scan, which will show bony obstruction.
as well as soft tissue anatomy (Fig. 10-1). Obtaining Depending on the surgeon’s preference, nasal
the scan with a protocol that could be used for intra- stents may be placed to maintain patency of the
operative image guidance equipment should be con- nares. A variety of methods and materials are avail-
sidered; this allows for minimally invasive endoscopic able to construct nasal stents (8, 9). Some may be
surgical techniques to be used, which can improve sur- entirely intranasal, and some project anterior to the
gical management of choanal atresia (6). It is helpful nares. Some are secured with sutures; others are
to suction the nares before scanning so that retained constructed to completely encircle the vomer (poste-
secretions do not obscure the anatomical findings. rior aspect of the nasal septum) and the collumella
(anterior, external aspect of the septum) and there-
Management and Treatment fore cannot be dislodged with suctioning or other
Short-term management of bilateral choanal manipulation. All stents require meticulous suction-
atresia can be accomplished by propping the in- ing to maintain patency; these narrow channels may
fant’s mouth open with a device such as an oral air- be the child’s only functional airway (Fig. 10-2). The
way or a feeding nipple with a large opening, which nares and collumella should be monitored for injury
is secured in place. It may be more practical, however, and necrosis.
to intubate the infant until surgery can be performed. Although unilateral choanal atresia is twice as
Definitive management is accomplished by creat- common as bilateral choanal atresia, it is generally
ing choanal openings surgically. If the choanal minimally symptomatic and well tolerated by infants
2831_Ch10_237-260 15/03/14 10:45 AM Page 241
is noted. In a subset of patients, however, there tonsillotomy (partial removal of the tonsils) or ton-
may be impaired weight and length growth despite sillectomy (complete removal of the tonsils) as appro-
an increased calorie diet and additional feeding priate. Placement of a nasopharyngeal airway can be
interventions. The mortality rate ranges from 0% very effective acute management.
to 13.6%, and the small number of children with Macroglossia (enlarged tongue) is common in in-
this disorder relative to the general population and dividuals with Down syndrome as well as other con-
differences in long-term patient management are ditions such as mucopolysaccharidosis (an inherited
probably responsible for the wide mortality rate disease that causes defects in bone, cartilage, and
range (18). connective tissue). Macroglossia can contribute to
airway obstruction, particularly during sleep when
Other Conditions Affecting the Oral there is decreased muscle tone (20). The treatment
for macroglossia is tongue reduction surgery.
Cavity and Oropharynx A peritonsillar abscess, also referred to as quinsy,
In tonsillar hypertrophy, the palatine tonsils, com- can develop in the potential space superolateral to
monly referred to as tonsils, which are situated be- the tonsil and is thought to be secondary to obstruc-
tween the anterior and posterior tonsillar pillars tion of the minor salivary glands in this region,
(palatoglossus and palatopharyngeus muscles, respec- known as “Weber’s glands.” Typical symptoms in-
tively), become enlarged, causing airway obstruction clude unilateral soft palate swelling, deviation of the
(Fig. 10-6). They can be enlarged secondary to acute uvula away from the infected side caused by mass
infection by various pathogens including bacteria effect, hot potato voice (muffled speech), dysphagia
such as streptococcus pneumonia or viruses such as (difficulty with swallowing), odynophagia (painful
Epstein-Barr virus (EBV) and infectious mononu- swallowing), trismus (decreased mouth opening
cleosis. Chronic tonsillar hypertrophy can also occur from masticator muscle spasm), and in severe cases
without an inciting etiology and can be associated airway obstruction. Management options include
with adenoid hypertrophy (the adenoids are located antibiotics, incision and drainage, and possibly
in the nasopharynx). Symptoms of tonsil enlarge- tonsillectomy (21).
ment can include snoring with apnea, stertor (noisy A retropharyngeal abscess occurs when a pocket
snoring), and dysphagia. Management includes an- of purulence develops behind the posterior pharyn-
timicrobials and/or surgical intervention such as geal wall, causing symptoms of neck stiffness, neck
pain, fever, and cervical adenopathy. Although in-
travenous antibiotic therapy can be sufficient to
manage early forms of this condition, definitive
treatment is surgical, often through an intraoral
approach (22).
Congenital vascular malformations can be arterial,
venous, lymphatic, or a combination of the three and
can cause airway obstruction. Within the tongue, the
most common vascular malformation is the micro-
cystic lymphangioma (traditionally called a cystic hy-
groma); because of its location, presenting symptoms
are often similar to those seen with macroglossia. Sur-
gical removal may be necessary.
symptoms of cough and choking or regurgitation. children with laryngomalacia will present with an
Moderate laryngomalacia is differentiated from additional comorbidity (25). To improve long-term
mild symptoms by an increased frequency of feed- outcomes, it is important to manage comorbidities
ing-related symptoms (29). Assessing the severity as the team is able.
of laryngomalacia can be challenging. Patients with
severe symptoms can have obstructive episodes with Other Conditions Affecting the
cyanosis, feeding difficulties, failure to thrive, and
cor pulmonale (30). Continuous monitoring, simi-
Supraglottis
lar to that used in a sleep study, may reveal episodes Epiglottitis, which anatomically is actually “supra-
of obstructive apnea and oxygen desaturation. glottitis,” is an uncommon but very serious condition
of swelling of the epiglottis that can cause sudden
Management and Treatment and complete airway obstruction. (Classic infectious
Most children with congenital laryngomalacia can epiglottitis is discussed in Chapter 16.) Epiglottitis
be managed expectantly. Respiratory management may also be caused by thermal, chemical, allergic,
for mild and moderate laryngomalacia is usually caustic (33), or mechanical injury.
minimal and will spontaneously resolve in the first Both vallecular cysts and ectopic (abnormally
year of life. Body positioning can often alleviate located) thyroid tissue may present as masses at the
much of the airway obstruction. Upright position- base of tongue or in the valleculae (space between
ing, such as in an infant seat during the daytime and the base of tongue and the epiglottis) (Fig. 10-9).
a side-lying position at night in a crib is often helpful. Both have the potential to cause feeding difficulties
If the obstruction is primarily from the epiglottis, and airway obstruction. Two hypotheses about the
prone positioning may provide airway relief. Intuba- etiology of vallecular cysts include obstruction of
tion could be considered, but is not generally neces- mucous gland ducts or embryological malformation
sary. Many children with laryngomalacia also are (34). Most are successfully treated with marsupial-
treated for GERD or the feeding difficulties that ization (unroofing the lesion) (34). Ectopic thyroid
arise from airway obstruction. tissue can be confirmed by a thyroid scan (35, 36),
Surgical management should be considered for which will also provide information about the
children with severe obstruction. Surgical procedures presence or absence of functional thyroid tissue in
are designed to release or trim the affected structures
using microlaryngoscopy and sharp dissection, mi-
crodebriders, or CO2 laser. The procedures may
be called “supraglottoplasty,” “epiglottoplasty,” or
“aryepiglottoplasty” (26, 31). Tracheotomy is not
commonly performed, but it may be necessary in a
small subset of patients who have additional neuro-
logical problems that decrease airway tone, and may
not be reversible.
Postoperatively, patients are generally managed in
an intensive care setting and monitored for oxygen
desaturation and symptoms of airway edema, such
as increased work of breathing and inspiratory stri-
dor. If intubated during surgery, they may be extu-
bated immediately postoperatively, or they may A
remain intubated overnight. Steroids and racemic ep-
inephrine may be prescribed after extubation. Initial Anterior
Laryngoscope
postoperative feeding is begun cautiously because blade
there is some risk of aspiration (32).
Course and Prognosis
The vast majority of infants will outgrow this dis-
order uneventfully (29) with no long-term sequelae.
Associated comorbidities include GERD or LPR,
neurological disease, congenital heart disease, con-
Epiglottis
genital anomalies or a syndrome, or the presence of
a secondary airway lesion. They are found more B Posterior
commonly in children with moderate and severe Figure 10-9 Vallecular Cysts (Courtesy of Ellen Deutch MD
disease. Excluding GERD or LPR, 25% to 50% of FACS, FAAP)
2831_Ch10_237-260 15/03/14 10:45 AM Page 247
frequent recurrences requiring more surgeries for re- tracheostomy (46). Other surgical management of
moval (39). In more severe cases, a tracheotomy may the adducted larynx is less common because some
be required. This step can be controversial because conditions will resolve after treatment or over time
there is concern about potentiating disease. and procedures to improve airway patency can com-
A number of adjuvant medical therapies have promise voice quality.
been administered, often with initial promising re- Unilateral vocal fold paralysis requires investiga-
sults and variable long-term results (Evidence in tion of the entire course of the recurrent laryngeal
Practice 10-1). nerve that supplies most of the motor function and
sensation to the larynx. This nerve is a branch of the
Course and Prognosis vagus nerve, and extends from the neck into the
Although there is no cure for RRP, it is a generally chest, with portions circling around the aorta and
benign disease when treated in a timely manner. The right subclavian artery before rising back into the
major burden on patients is through voice dysfunc- neck and innervating the larynx. A common cause
tion, although there is a significant social and eco- of unilateral vocal fold paralysis is iatrogenic injury
nomic burden on the patient and family. Children are during cardiac or thyroid surgery. Like bilateral
frequently hospitalized for surgeries, and there is a paralysis, the presentation can vary between stridor
negative social stigma regarding HPV that causes from airway obstruction when the cord is paralyzed
stress for families affected by RRP. It can recur in an adducted position and aspiration when the
throughout a patient’s life span, sometimes after as paralyzed cord has an overall abducted position.
much as a 20-year remission (45). The paralyzed cord can recover spontaneously or,
over time, the normal vocal cord may compensate
Other Conditions Affecting the Glottis for the weaker paralyzed one (47). In some cases,
surgical interventions may be considered, such as
Vocal fold paralysis (also known as vocal cord injection of the vocal fold with a filler material if
paralysis) is the interruption of laryngeal nerve im- the cord is abducted or recurrent laryngeal nerve
pulse, which controls vocal cord movement. It is the reinnervation (47).
second most common laryngeal anomaly after Another condition that can affect the glottis is
laryngomalacia. It can be bilateral or unilateral known a glottic web, which is a membrane spread be-
and is often the result of a neurological abnormal- tween the vocal folds near the anterior commissure.
ity. Bilateral vocal fold paralysis must always be in- This results from incomplete development of the
vestigated for a central source such as intracerebral laryngeal opening in utero and appears as a web just
hemorrhage, hydrocephalus, or even Arnold-Chiari posterior to the anterior commissure, which is the
malformation, which can result in herniation of the anterior junction of the two vocal cords. This condi-
brainstem (30). tion can occur as an isolated condition or can be
Bilateral vocal fold paralysis can result in cords associated with syndromes such as 22q11, formerly
that are in an abducted (spread apart or open) resting known as velocardiofacial syndrome (48). Webs can
position or alternatively are in an adducted (apposed also develop iatrogenically after intubation trauma,
or closed) position. If the cords are abducted, then aggressive removal of papillomatosis at the anterior
the child might present with a breathy voice or even commissure, or other interventions. Management
aspiration from inability to close the glottis during may consist of endoscopic lysing of the web or sur-
swallowing. Children with adducted cords present gical excision and/or laryngotracheal reconstruction,
with stridor and airway obstruction but may have with the extent of surgery dependent on the thick-
a normal voice. This condition often requires a ness of the web.
Vocal fold nodules can also result in hoarseness
and are thought to be caused by vocal abuse. Typi-
● Evidence in Practice 10-1 cally, these callus-like lesions develop at the junc-
tion between the anterior and middle third of the
Treatments for RRP vocal folds. The nodules can be acute and soft, or
Recent examples of adjuvant medical therapies chronic and more mature. Management typically
for RRP include interferon alpha, mumps vaccine, targets the primary cause using speech language
indole-3-carbinol, and intralesional cidofovir (41). therapy. Surgical intervention is uncommon, but it
Systemic propanolol is also under investigation (43). may be warranted in selected cases.
Gardasil prophylactic vaccinations are now recom- The reflux of gastric contents superiorly through
mended by the American Academy of Pediatrics for the esophagus to the pharynx (LPR) can cause in-
both boys and girls (44); the effect on airway lesions flammation of the posterior region of the larynx. The
is not yet known. reflux can also cause laryngeal changes including
swelling of the supraglottic and glottic structures and
2831_Ch10_237-260 15/03/14 10:45 AM Page 249
Pathophysiology
In patients who have congenital subglottic stenosis, ■ ■ BG Walters initially tolerated extubation well,
the airway lumen is elliptical rather than round, and requiring CPAP at 7 cm H2O and FIO2 at 0.30. About
vocal fold function is normal (42, 50). In subglottic 20 minutes postextubation, you begin to hear inspi-
stenosis caused by endotracheal intubation, the endo- ratory stridor that does not improve by moving her
tracheal tube can damage the mucosa and underlying to an upright position or administering a one-time
2831_Ch10_237-260 15/03/14 10:45 AM Page 250
inhaled racemic epinephrine treatment. You also note A cricotracheal resection may be indicated in select
that she has moderate substernal retractions and cases when there is a very circumscribed or very se-
nasal flaring. After another 20 minutes, BG Walters’ vere area of narrowing. In this procedure, rather than
FIO2 has been increased to 0.60 to maintain her expanding the narrowed area, the stenotic portion
SpO2 at greater than 90%. You call the physician and the surrounding cartilage is completely removed,
back to the baby’s bed to reevaluate her. You, the and the distal and proximal ends of the gap in the air-
nurse, and the physician all agree that BG Walters’ way are reconnected. Risks include vocal fold paral-
respiratory distress is unlikely to improve and decide ysis because surgical dissection is carried out in the
to reintubate. The physician will attempt once and region of the recurrent laryngeal nerve (53). Children
agrees to contact pediatric anesthesia if he has any may have a suture placed between the chin and chest
difficulty during the procedure. to prevent neck extension from causing distraction
forces on the anastomosis. Potential postoperative
complications include separation of the reconstructed
airway, which can be disastrous and may be initially
evidenced by subcutaneous air (42). Reintubation
Several of the surgical procedures used to manage
must always be completed very cautiously because
subglottic narrowing involve mechanically enlarging
there is a risk of intubating through an existing false
the cartilaginous framework of the airway. A cricoid
passage or creating a new one.
split is based on the principle that the cricoid carti-
Alternatively, a tracheostomy may be the most
lage forms a complete ring, and incising the ring
prudent option if there are circumstances that war-
allows it open slightly more, thereby expanding the
rant postponing reconstruction until the child’s con-
airway lumen. This procedure is completed in
dition or other circumstances can be optimized. A
neonates who are medically stable and require
tracheostomy tube is placed in the trachea, distal
only minimal ventilatory support (53). The proce-
(inferior) to the subglottis, and bypasses this level of
dure entails exposure and vertical incision of the
narrowing.
most anterior midline portion of the cricoids, which
While the factors affecting susceptibility to sub-
allows the ring to spring open a small amount.
glottic stenosis in an individual patient are not com-
Typically, the infant is extubated 7 to 10 days
pletely understood, it seems prudent to always handle
postoperatively.
the airway gently and to optimize pulmonary
Laryngotracheal reconstruction is generally an
function to decrease the need for mechanical
open procedure that involves expanding the laryn-
support. These additional considerations may be
geal airway caliber with an anterior and possibly
helpful:
posterior cartilage graft, often taken from the thyroid
cartilage or even more commonly the cartilaginous 1. Minimize trauma by using gentle technique
portion of a rib. It can be completed in one or two when intubating and avoid repeated attempts
stages, plus follow-up endoscopic management. A (e.g., the more difficult the intubation may be,
single-stage procedure includes inserting the graft(s), the greater the expertise required of the person
removing the existing tracheostomy tube, and closing performing the intubation).
the tracheostomy defect. These children leave the op- 2. Use the smallest effective endotracheal tube
erating room with an oral or nasal endotracheal tube (ETT), considering the size of patient’s airway
in place and are extubated days later. In a two- or and the ventilatory requirements. An ETT
double-stage procedure, the airway is reconstructed, smaller than predicted may be required in
but the tracheostomy is left in place distal to the infants and children with known subglottic
area of reconstruction with intention to decannulate pathology.
after a longer time interval and after adequate airway 3. Secure the ETT well and minimize the fric-
patency has been confirmed. A short-term stent may tional forces caused by motion of the tube and
be secured within the reconstructed area postopera- patient relative to each other, such as during
tively. When a stent is placed, endoscopic removal is patient repositioning. This may require retap-
required, which can be problematic in the event of ing an ETT whenever it is noted to move freely
an airway emergency, such as a broken stent (54). from the lip or cheek so that the distal tip of
In selected cases, a cartilage graft is placed in the the tube does not rub against the subglottic
posterior aspect of the cricoid cartilage endoscopi- airway.
cally (55). In each of these scenarios, there is antici- 4. Manage suspected GERD or LPR. The
pation of graft vascularization and graft survival to reflux may already be exacerbated by the
maintain the expansion of the airway lumen. Laryn- retractions and respiratory effort that create
gotracheal reconstruction can have a number of strong negative intrathoracic pressure and
complications, including pneumothorax from graft pull effluent from the esophagus and stom-
harvest, graft resorption, or even graft dislodgement. ach to the laryngopharynx (42, 53).
2831_Ch10_237-260 15/03/14 10:45 AM Page 251
■ ■ After reintubating with a 3.5 cuffless ETT, the 6 months and 3 years of age. This is most often a viral
physician contacts BG Walters’ parents to discuss disease that causes airway narrowing involving the
the possibility of subglottic stenosis. He recommends subglottis; it presents with a “barky” cough, stridor,
an otorhinolaryngology consult, to which they readily and occasionally hoarseness. Mild cases can be
agree. managed conservatively; severe cases with sig-
Endoscopy performed by the pediatric ear, nose, nificant respiratory distress may require treatment
and throat (ENT) specialist uncovers a grade II steno- with racemic epinephrine and systemic steroids (61).
sis. The ENT surgeon recommends a tracheostomy Intubation is avoided except in severe cases of respi-
tube to allow mechanical ventilation weaning and ratory failure. In children who develop symptoms of
multisystem stabilization prior to tracheal reconstruc- croup before 6 months of age, or who have repeated
tion. BG Walters’ parents agree to the tracheostomy episodes of croup, additional underlying conditions,
tube, but request a more specific timeline and goals such as subglottic stenosis, should be considered.
for her management and plan of care, which the mul-
tidisciplinary teams will build over the coming week. Airway Abnormalities of the Trachea
and Bronchi
The airway below the glottis and vocal cords begins
Other Conditions Affecting the the lower respiratory system. Despite having the
vocal cords as a protective mechanism, infection of
Subglottis the airway and foreign bodies are still potential
Subglottic cysts can also present in the subglottic threats to the trachea and bronchi. In addition, the
region. They can be congenital (56), but are more posterior layers of the trachea interface with the
frequently acquired secondary to endotracheal intu- anterior tissue layers of the esophagus, so both con-
bation. Interestingly, duration of intubation is not genital and acquired conditions affecting the esoph-
thought to be a key factor in the development of agus may also affect the trachea. The congenital
subglottic cysts (57); premature birth and GERD are malformation most commonly cared for by RTs is
often seen as associated factors (58). Subglottic cysts esophageal atresia/tracheoesophageal fistula. Other
tend to occur more frequently on the left side. disorders that can cause significant respiratory dis-
One theory postulates that because most indi- tress include exudative tracheitis, tracheal masses,
viduals are right-handed, and most intubation laryn- and tracheal compression.
goscopes are designed for right-handed intubation,
they may exert more pressure, and subtle trauma, on Tracheoesophageal Fistula
the left side of the subglottis during intubation (57).
Subglottic cysts may sometimes be apparent ra- Esophageal atresia (EA) is a congenital defect in which
diographically, but definitive diagnosis is achieved the esophagus ends in a blind-ended pouch rather
endoscopically. Management is through excision than connecting normally to the stomach. A form of
or marsupialization (unroofing) of the cyst, which EA may also involve a connection between the esoph-
can be completed with microlaryngeal instruments, agus and the trachea, known as a tracheoesophageal
a microdebrider, or CO2 laser. Intubation itself can fistula (TEF). TEF can lead to severe pulmonary com-
sometimes rupture the cysts. Subglottic cysts can plications and requires a multidisciplinary approach
recur, and thus vigilance is warranted. Repeat eval- to manage both the digestive and respiratory malfor-
uations with bronchoscopy are often completed. mations. TEF occurs in about 1 in 3,500 births (62).
Recent evidence suggests that treatment with the
chemotherapeutic agent mitomycin C applied topi- Pathophysiology
cally to the subglottis can reduce the incidence of Esophageal atresia occurs when the embryonic
recurrence (58). tracheoesophageal septum develops improperly. At
A subglottic hemangioma is an abnormal buildup around week 4 of gestation, the airway begins to
of blood vessels in the subglottic tissue, which can grow out from the foregut, which means that during
cause airway obstruction. Subglottic hemangiomas normal embryological development the trachea and
tend to increase in size for the first 8 to 12 months of esophagus are connected. The mechanism of how
life, and then regress spontaneously (59). Traditional the esophagus and trachea grow and separate is still
management includes steroids; recent evidence sug- not fully understood. TEF is a failure of the esoph-
gests that propranolol also may be effective (60). agus and trachea to separate in utero, which nor-
In severe cases, endoscopic or open resection, or a mally occurs sometime prior to week 18 of gestation
tracheotomy, may be indicated. (63). Although isolated esophageal atresia can
Laryngotracheobronchitis (croup) is a condition occur, more than 80% of infants with esophageal
that occurs in up to 15% of children, typically between atresia have a proximal esophagus that ends in a
2831_Ch10_237-260 15/03/14 10:45 AM Page 252
blind pouch and also have a distal TEF (64), which • Choking or difficulty managing airway, accom-
allows esophageal contents to reflux into the airway. panying cyanosis
Several other variations of EA are also possible (64) • Barking cough
(Fig. 10-11). About half of infants with esophageal • Respiratory distress, worsening during feeding
atresia will also have an additional congenital anom- • Inability to accept orogastric tube into the
aly that may be musculoskeletal, gastrointestinal, stomach
cardiac, or genitourinary; the additional abnormal-
TEF is often associated with anatomic tracheoma-
ity is often also one that occurs along the vertical
lacia, which is characterized by a widening of the pos-
axis (known as a midline defect) (64).
terior, membranous component of the trachea and a
Clinical Manifestations flattened anterior-posterior diameter of the trachea.
(The tracheal “rings” are actually arches, and the
TEF is normally identified in utero using sonogra-
common wall between the trachea and the esophagus
phy, and it is one of the key congenital malforma-
is membranous.) Functional tracheomalacia is char-
tions ruled out during the 20-week prenatal anatomy
acterized by abnormally increased collapsibility of
sonography screening. Sonographic evidence in-
the trachea, particularly during inspiration. Tracheo-
cludes polyhydramnios, absence of a fluid-filled
malacia can also occur as residual after tracheotomy.
stomach, small abdomen, lower-than-expected fetal
Tracheomalacia can cause stridor. Congenital tra-
weight, and distended esophageal pouch.
cheomalacia tends to improve with maturation or
TEF may also be suspected after delivery when a
with repair of the extrinsic cause, but resolution of
newborn presents with one or more of the following:
symptoms is often very gradual.
• Excessive drooling, with copious, fine white After delivery, a chest radiograph will verify the
frothy oral secretions, which will recur despite presence of the TEF. Insertion of a nasogastric tube
suctioning may show coiling in the mediastinal area. Contrast
A C
B D
Figure 10-11 Tracheoesophageal Fistula (Courtesy of Ellen Deutch MD FACS, FAAP)
2831_Ch10_237-260 15/03/14 10:45 AM Page 253
placed for long-term airway stabilization. The per- A tracheotomy stoma is considered unstable until
manent opening that is created during the surgery is the surgical site has healed sufficiently to decrease
known as a tracheostomy. The indications for place- the risk of creating a false passage during tra-
ment of tracheostomy tubes in children are different cheotomy tube changes. The first tracheotomy tube
from that of adults and are described in Box 10-1. change is generally performed by the surgeon to
A tracheotomy creates an opening in the proximal confirm adequate healing and can thereafter be del-
trachea, below the larynx, and therefore below the egated to appropriately trained health-care profes-
glottis (vocal folds) and the subglottis. Tracheotomies sionals and family members. The first tracheotomy
bypass lesions located above the tracheotomy, includ- tube change is often accomplished 5 to 7 days after
ing conditions affecting the larynx, pharynx, oral surgery, but it can be safely accomplished as soon as
cavity, nose, and face. In children, tracheostomy 3 days postoperatively; the decision about this tim-
tubes are most often placed for upper or central ing is at the discretion of the surgeon (76). Stay su-
airway obstruction, followed in frequency by pul- tures are generally removed at the first tracheotomy
monary conditions that benefit from mechanical tube change. Some institutions allow health-care
ventilation, and then by conditions associated with providers to change the tracheotomy tube ties before
neurological impairment (71). Examples of conditions the first tracheotomy tube change; others do not
that may require tracheotomy to bypass airway ob- because of the potential for unintentionally dislodg-
struction include subglottic stenosis, subglottic heman- ing the tracheotomy tube during manipulation of
giomas, and craniofacial syndromes such as Robin the ties.
sequence, Treacher Collins syndrome, CHARGE Like adult tracheotomy tubes, pediatric tubes can
association, and others. The most common pediatric be cuffed or uncuffed. Pediatric tubes also are avail-
pulmonary condition that may require tracheotomy able in both pediatric and neonatal sizes; comparably
for prolonged mechanical ventilation is BPD (72). sized tubes have the same inner and outer diameters,
Examples of neurological conditions for which tra- but neonatal tubes are shorter. The distance between
cheotomies can be helpful include cerebral palsy and the chin and the chest in an infant is limited, and the
encephalopathy (71–75). universal adaptor allowing connection to ventilator
In pediatric patients, tracheotomy stay sutures are tubing or other devices may not fit easily into this
placed in the edge of the trachea, on either side of the space. Some tracheotomy tubes have an extension ex-
tracheal incision. If the tracheotomy tube is prema- ternal (anterior) to the neck flange, which allows the
turely dislodged, these ties can be grasped to help pull universal adaptor to be located further from the
the incision open, exposing the stoma to facilitate child’s neck, minimizing local trauma and facilitating
reinsertion of the tube. Care should be taken to keep normal head position. Unlike adult tracheostomy
the right and left ties separated and oriented correctly. tubes, most pediatric tracheostomy tubes do not have
It is less common in children to surgically “mature” an inner cannula, so a tracheostomy tube change,
the stoma by suturing tracheal cartilage to the skin, whether routine or emergent, requires removing the
and emergent cricothyrotomy and “bedside” tra- entire tracheostomy tube. Tracheostomy ties are
cheotomy procedures are uncommon in children. available in a variety of materials and should be snug
but not constricting. To change a pediatric tra-
cheostomy tube, follow the following steps: (77)
• Wash your hands.
Box 10-1 Indications for Tracheostomy for
• Explain the procedure to the patient and family.
Adults and Children
• Suction the airway using sterile technique.
• Prepare a new tracheostomy tube using sterile
Adults (70) technique.
Prolonged respiratory failure • Place ties or holder in the neck plate of new tube.
Decreased level of consciousness • Place the obturator (also called introducer)
Poor airway protective reflexes into new tracheostomy tube.
Severe alterations in physiology associated with • Lubricate the end of the new tracheostomy
trauma or medical illness tube with water-soluble lubricant.
Children (57) • Extend the patient’s neck.
To bypass upper and central airway obstruction • Cut tracheostomy ties or release tube secure-
Provides access for prolonged mechanical ment device.
ventilation • If a cuffed tracheostomy tube is in place, com-
To facilitate tracheobronchial hygiene pletely deflate cuff.
Neurological impairment • Gently remove the entire tracheostomy tube.
Bronchopulmonary dysplasia • Immediately insert the new tube by performing
a downward, inward motion.
2831_Ch10_237-260 15/03/14 10:45 AM Page 255
■ Case 4: Jackson Black nursery to see BG Hawk, who is just 10 hours old.
You are the RT covering the emergency depart- She was born after a full-term gestation and had
ment (ED) at a 200-bed suburban hospital. Apgar scores of 9 at 1 and 5 minutes. Initial physi-
Jackson Black’s parents have brought him to the cal examination was remarkable only for a slight
ED for respiratory distress. He is 4 years old with increase in white oral secretions, which cleared
hoarseness that is so severe that he has no voice with suctioning. She reportedly tolerated her first
at all, but is able to communicate verbally in a feeding, nursing for about 10 minutes. She is now
limited fashion using a very hoarse whisper. His noted to have crackles on routine auscultation. At
parents say that he has been hoarse for as long the time crackles were noted, she had a normal
as they can remember, but it has gotten progres- respiratory rate and increased oral secretions. A
sively more severe, and now they notice that his 10 French nasogastric tube could not be passed
breathing has become noisy and effortful. When beyond 10 cm.
you listen, you hear stridor, which is predomi-
• What is the most likely diagnosis?
nantly inspiratory and low-pitched.
• What temporizing measures would you rec-
• What initial therapies could help alleviate ommend to manage BG Hawk’s airway while
Jackson’s stridor? awaiting her transfer to a larger pediatric
surgery center?
Unfortunately, treatment with steroids and racemic
epinephrine are unsuccessful. You review the pa- ■ Case 7: BB Turner
tient’s chart and find a diagnosis of recurrent respi- BB Turner, a 6-month-old, who had been born
ratory papillomatosis. prematurely, underwent tracheotomy at 4 months
of age for BPD and ventilator dependence. His
• How is this treated?
pulmonary disease has been gradually improving,
■ Case 5: James Brody and his ventilator settings have been stable. When
You are a neonatal RT in a level III NICU caring you walk into his room, his oxygen saturation is a
for James Brody. He is 6 months old, born at bit lower than usual, and he seems to be working
24 weeks’ gestation, and has been successfully harder to breathe.
weaned to minimal ventilator support. Several at-
• What do you think might be happening? What
tempts to extubate him have been unsuccessful
can you do immediately to assess him?
because he develops stridor, which is primarily in-
• What would be your next course of action?
spiratory, and work of breathing has significantly
• You call for assistance to change his tra-
increased, requiring reintubation.
cheostomy tube, obtain the appropriate
• What can you do to improve his chances of supplies and equipment, position him with
success at the next extubation attempt? his neck extended, and remove his tra-
cheotomy tube. When you try to insert the
■ Case 6: BG Hawk
new tube, you are unable. What should
You are the day shift RT at a 75-bed rural commu-
you do now?
nity hospital and are called down to the newborn
Multiple-Choice Questions
1. You suspect that a newborn has choanal atre- you adjust his mask, you notice some duskiness
sia. What can you do to help her immediately at the bridge of his nose under the cuff of the
in this acute situation? mask. You should:
a. Attach a nasal cannula with supplemental a. Notify his care team because this may be
oxygen evidence of deeper tissue damage
b. Place a face mask with supplemental oxygen b. Make sure he is receiving an appropriate
c. Open her mouth antibiotic
d. Alert personnel who can place a laryngeal c. Ask the physician to discontinue BPAP ther-
mask airway apy and change to another oxygen delivery
2. You are caring for a young child with severe device
developmental delays who requires bilevel posi- d. Not worry; this is a common finding with
tive airway pressure (BPAP) support. When BPAP masks
2831_Ch10_237-260 15/03/14 10:45 AM Page 257
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8. Corrales CE, Koltai PJ. Choanal atresia: current concepts 30. Cotton RT, Prescott CAJ. Congenital anomalies of the
and controversies. Curr Opin Otolaryngol Head Neck Surg. larynx. In: Cotton RT, Myer CM III, eds. Practical Pedi-
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9. Durmaz A, Tosun F, Yldrm N, Sahan M, Kvrakdal C, 1999:497-513.
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and rhinorrhea. In: Bluestone CH, Stool SE, eds. Pediatric assisted supraglottoplasty for laryngomalacia. Ann Otol
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908-923. 33. Yen K, Flanary V, Estel C, Farber N, Hennes H. Traumatic
11. Elloy MD, Cochrane LA, Albert DM. Refractory choanal epiglottitis. Pediatr Emerg Care. 2003;19(1):27-28.
atresia: what makes a child susceptible? The Great Ormond 34. Gutierrez JP, Berkowitz RG, Robertson CF. Vallecular
Street Hospital experience. J Otolaryngol Head Neck Surg. cysts in newborns and young infants. Pediatr Pulmonol.
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atresia repair in the neonate. Arch Otolaryngol Head Neck Vepakomma D. Lingual thyroid gland: clinical evaluation
Surg. 2008;134(10):1090-1093. and management. Indian J Pediatr. 2004;71(12):e62-e64.
13. Allam KA, Wan DC, Kawamoto HK, Bradley JP, Sedano 36. Rahbar R, Yoon MJ, Connolly LP, et al. Lingual thyroid
HO, Saied S. The spectrum of median craniofacial dysplasia. in children: a rare clinical entity. Laryngoscope. 2008;118(7):
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14. van Kempen MJ, Rijkers GT, Van Cauwenberge PB. The 37. Mussak EN, Kacker A. Surgical and medical management
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Immunol. 2000;122(1):8-19. 2007;136(6):870-872.
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Pediatr Clin North Am. 1989;36(6):1551-1569. Head Neck Surg. 1993;109(4):766-768.
16. Mackay DR. Controversies in the diagnosis and manage- 39. Wiatrak BJ, Wiatrak DW, Broker TR, Lewis L. Recurrent
ment of the Robin sequence. J Craniofac Surg. 2011;22(2): respiratory papillomatosis: a longitudinal study comparing
415-420. severity associated with human papilloma viral types 6 and
17. Evans AK, Rahbar R, Rogers GF, Mulliken JB, Volk MS. 11 and other risk factors in a large pediatric population.
Robin sequence: a retrospective review of 115 patients. Int Laryngoscope. 2004;114(11, pt 2, suppl 104):1-23.
J Pediatr Otorhinolaryngol. 2006;70(6):973-980. 40. Derkay CS. Task force on recurrent respiratory papillomas.
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2010;52:167-172. 41. Schraff S, Derkay CS, Burke B, Lawson L. American soci-
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tive sleep apnea in patients with cleft palate. Arch Otolaryngol recurrent respiratory papillomatosis and the use of adju-
Head Neck Surg. 2011;137(3):269-274. vant therapy. Arch Otolaryngol Head Neck Surg. 2004;130(9):
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Chapter 11
Acyanotic Heart
Defects
Chapter Outline Key Terms
Chapter Objectives Angioplasty
Key Terms Aortic stenosis
Carly Jo Johnson Atrial septal defect (ASD)
Septal Wall Defects Atrioventricular septal defect
Atrial Septal Defect Bicuspid
Pathophysiology Cardiac murmur
Clinical Manifestations Cardiomegaly
Management and Treatment Coarctation of the aorta
Course and Prognosis Complete vascular ring
Ventricular Septal Defect Coronary sinus
Pathophysiology Doppler interrogation
Clinical Manifestations Double aortic arch
Management and Treatment Echocardiogram
Course and Prognosis Endocarditis
Atrioventricular Septal Defects “Fixed” split S2
Pathophysiology Hypertrophy
Clinical Manifestations Myocardial ischemia
Management and Treatment Ostium primum ASD
Course and Prognosis Ostium secundum ASD
Aortic Stenosis Paradoxical split
Pathophysiology Perimembranous ventricular septal
Clinical Manifestations defect
Management and Treatment Pulmonic stenosis
Course and Prognosis Pulse pressure
Pulmonic Stenosis Septum
Pathophysiology Septum primum
Clinical Manifestations Septum secundum
Management and Treatment Sinus venosus
Course and Prognosis Valvotomy
Coarctation of the Aorta Valvuloplasty
Pathophysiology Ventricular septal defect
Clinical Manifestations
Management and Treatment
Course and Prognosis
Double Aortic Arch
Pathophysiology
Clinical Manifestations
Management and Treatment
Course and Prognosis
261
2831_Ch11_261-278 13/03/14 3:34 PM Page 262
Chapter Objectives
After reading this chapter, you will be able to:
1. Identify the common types of acyanotic heart defects diagnosed in children.
2. Identify the two most common acyanotic heart defects.
3. Explain the anatomical variations of different acyanotic heart defects.
4. Discuss the clinical signs and symptoms associated with each heart defect.
5. Explain how the pathophysiology of acyanotic heart defects can mimic pulmonary disease.
6. Differentiate between murmurs found in acyanotic heart defects.
7. Describe the surgical management and treatment strategies for acyanotic heart defects.
8. List the indications for closing a septal wall defect.
9. Describe the respiratory symptoms that may manifest in a patient with a double aortic arch.
A
pproximately 1% of infants suffer from con- • Electrocardiogram (EKG): reading of the
genital heart disease, which refers to heart electrical activity of the heart
diseases or defects present at birth, usually • Chest radiograph
caused by hereditary factors (1). Many different • Echocardiogram: using ultrasound to visualize
structural abnormalities can lead to the diagnosis of cardiac structures noninvasively
2831_Ch11_261-278 13/03/14 3:34 PM Page 263
Soft systolic ejection murmur Along upper left sternal border Atrial septal defect
“Fixed” split S2
Harsh holosystolic murmur Loudest at fourth intercostal Ventricular septal defect
space, but may be heard
throughout the chest
Harsh, loud systolic ejection murmur Aortic stenosis
Ejection click
Paradoxical split
Systolic ejection murmur, with or Left upper sternal border Pulmonic stenosis
without click
“Fixed” split S2
Continuous flow murmur Coarctation of the aorta
2831_Ch11_261-278 13/03/14 3:34 PM Page 264
directly adjacent to the atrioventricular valves (tri- double-patch method. The common AV valve leaflets
cuspid and mitral). AVSDs comprise approximately must then be separated into two valve orifices—one
5% of people with congenital heart disease (8). This for the right AVV and one for the left AVV.
defect is especially common in the subpopulation of
children with trisomy 21 (or Down syndrome). Course and Prognosis
Operative mortality from repair of a complete AV
Pathophysiology canal, reported at 0% to 8.7%, is usually higher than
The endocardial cushions (as mentioned in the sec- isolated atrial or ventricular septal defects (9, 10).
tion on ASDs) are segments of tissue that form a Recent literature suggests that outcomes are no dif-
platform for the development of the atrial septum, ferent in children repaired at less than 3 months of
ventricular septum, and atrioventricular valves. Any age compared with those greater than 3 months (11).
growth abnormality involving the endocardial cush- The prognosis depends, in part, on the residual val-
ions can result in defects in the lower portion of the var lesions, most commonly left AV valve regurgita-
atrial septum (ostium primum ASD), defects in the tion or stenosis. The most common reason for
ventricular septum (inlet VSD), and/or structural reoperation is left AV valve (mitral valve) regurgita-
abnormalities in the atrioventricular (AV) valves. tion, which occurs in 6% to 11% of children after
There are three types of AVSDs: AVSD repair (9, 12).
• Partial (incomplete): consists of a defect in the
ostium primum (see section on ASDs), as well Aortic Stenosis
as an abnormality of the mitral valve
• Transitional: involves defects in the ostium Aortic stenosis is defined as any discrete narrowing
primum and in the ventricular septum that is that occurs between the left ventricle and the aorta
usually restrictive. There are two distinct AVV (Fig. 11-3). It can occur at the level of the aortic
valves that usually have abnormal leaflets. valve, above the valve (supravalvar), or below the
• Complete: defined by a defect in the ostium valve (subvalvar). Obstruction at the level of the aor-
primum, a large inlet-type VSD (see section on tic valve is by far the most common type of aortic
VSDs), and one common AV valve with multi- stenosis (70% to 80%) and is the focus of this section.
ple leaflets instead of two distinct AV valves In children, aortic stenosis represents 6% of congen-
ital heart disease (13).
Clinical Manifestations Pathophysiology
The clinical manifestations of an AVSD completely
depend on the subtype. A partial (incomplete) The aortic valve consists of three smooth leaflets that
AVSD may not demonstrate any signs or symptoms open during systole (contraction of the heart cham-
and could go undetected until adulthood. The symp- ber muscles) and close during diastole (relaxation of
toms of an AVSD occur because of unrestricted the cardiac muscles) to prevent backflow of blood
pulmonary blood flow as a result of significant left- into the left ventricle. The most common cause of
to-right shunting across the VSD component. aortic valve stenosis is a bicuspid aortic valve, mean-
Patients often present with respiratory distress from ing that the aortic valve consists of two functional
pulmonary edema and symptoms of heart failure, leaflets instead of three. Because these leaflets have
which include the following:
• Poor feeding
• Difficulty gaining weight
• Fatigue
• Excessive sweating with feeds or activity
Supravalvar
Management and Treatment Left atrium
Patients with symptomatic AVSDs may be managed
Mitral valve
with medical therapy, including diuretics, systemic Valvar
afterload reduction with ACE inhibitors, and intropes Aortic valve
(i.e., digoxin). Definitive therapy involves surgical Subvalvar
repair. Repair of the partial AVSD includes closure of
the defect in the ostium primum with a patch and Left
suture repair of the abnormality in the mitral valve ventricle
(usually a mitral valve cleft). Surgical repair of a com-
plete AV canal can be quite challenging. The atrial and
ventricular septal defects are closed with a single- or Figure 11-3 Aortic Stenosis
2831_Ch11_261-278 13/03/14 3:34 PM Page 269
stimulation and decreased apnea frequency. If blood to leave the right ventricle and enter the
apnea continues, the neonate will need to be sup- pulmonary artery. Pulmonic stenosis most com-
ported with intubation and mechanical ventilation. monly occurs at the level of the pulmonary valve but
can occur above (supravalvar) or below (subvalvar).
Course and Prognosis Pulmonic stenosis results from abnormally formed
Children with congenital aortic valve stenosis will valve leaflets that may be dysplastic (as in Noonan
most likely develop progressive obstruction over syndrome) or form an abnormal dome shape.
time. When left untreated, severe aortic stenosis puts Obstruction in the right ventricular outflow tract
the patient at risk for sudden cardiac death and from pulmonic stenosis causes increased workload
infective endocarditis, or inflammation of the heart on the right ventricle and subsequent right ventricu-
valves. It is important that children are followed lar hypertrophy. Like aortic stenosis, pulmonic
over time to document worsening obstruction or stenosis can be classified as mild, moderate, or
development of symptoms that necessitate therapy. severe, depending on the degree of obstruction.
Outcomes after balloon dilation are usually excel-
lent, with 87% of children experiencing a significant Clinical Manifestations
reduction in the severity of obstruction (16). Over Children with mild pulmonic stenosis will usually
time, some children will have recurrence of obstruc- have no symptoms. However, children with moder-
tion and may need a repeat dilation. There are no ate to severe pulmonic stenosis may present with the
data to suggest that using balloon dilation on the following symptoms due to increased right ventric-
aortic valve versus surgical valvotomy have different ular afterload:
success rates or frequency of restenosis (17).
• Dyspnea on exertion
• Fatigue
Pulmonic Stenosis • Cyanosis
Pulmonic stenosis, also known as pulmonary valvar Severe pulmonic stenosis can progress to early
stenosis, refers to a narrowing in the right ventricular right ventricular failure. On clinical examination,
outflow tract between the right ventricle and the patients will exhibit a systolic ejection murmur, loud-
main pulmonary artery (Fig. 11-4), occurring in 7% est at the left upper sternal border, with or without
of all patients with congenital heart disease (1). It an ejection click. Auscultation may also exhibit a
can occur as an isolated lesion or along with other “fixed” split S2, due to increased ejection time across
cardiac anomalies, including tetralogy of Fallot, the stenotic pulmonic valve. Palpation of the pre-
VSD, and double-outlet right ventricle. cordium, done by placing a hand over the location of
the heart on the thorax, may reveal an increased right
Pathophysiology ventricular impulse or “heave.” Cyanosis occurs if
Like the aortic valve, the pulmonic valve consists of the elevated pressure in the right ventricle is causing
three leaflets that open during systole, allowing deoxygenated blood to shunt right to left across the
atrial septum through a patent foramen ovale.
A 12-lead EKG will often demonstrate right axis
deviation, right ventricular hypertrophy, and a right
Stenotic pulmonary valve bundle branch block in cases of moderate to severe
stenosis. Echocardiography is an excellent way to
Thickened assess the pulmonic valve for anatomy, size, and
leaflets
degree of obstruction.
Narrowed
valve Management and Treatment
opening
Mild pulmonic stenosis needs no therapy. Moderate
to severe pulmonic stenosis often requires therapy
because of progressive symptoms of exercise intoler-
Pulmonary
artery ance or right ventricular failure. Interventions can
include a transcatheter balloon valvuloplasty, a sur-
Pulmonary gical valvotomy, or valve replacement performed in
valve the OR. The cyanotic neonate with critical pulmonic
Left
stenosis is dependent on a patent ductus arteriosus
ventricle (see Chapter 8) to maintain adequate pulmonary
blood flow. Prompt initiation of prostaglandin
therapy (PGE1) will maintain a patent ductus arte-
Figure 11-4 Pulmonic Stenosis riosus and is necessary for stabilization of a neonate
2831_Ch11_261-278 13/03/14 3:34 PM Page 271
Aorta Pathophysiology
A coarctation involves the extension of a shelf-like
Left atrium structure into the lumen of the aorta. On a pathol-
ogy specimen, this “shelf” actually represents
Pulmonary
artery
thickening of the first two layers of the aortic vessel:
Right the intima (the innermost layer) and the media
atrium (a middle layer made mostly of muscle cells). Two
Left
ventricle theories exist regarding the cause of an aortic
Right coarctation:
ventricle
• Reduced blood flow through the aortic arch
during intrauterine development
• Constriction of ductal tissue that extends into
Figure 11-5 Coarctation of the Aorta the aortic lumen
2831_Ch11_261-278 13/03/14 3:34 PM Page 272
The coarctation is usually located directly of the narrowed blood vessel) in the catheterization
opposed to the lumen of the ductus arteriosus and laboratory. Success rates following a balloon angio-
may worsen after ductal closure, which supports the plasty have been reported at 88% (19).
second theory. The area of coarctation in the
descending aorta acts as an obstruction to left ven- Course and Prognosis
tricular outflow causing increased left ventricular Depending on the degree of obstruction, patients
afterload. may go several years before being diagnosed with
aortic coarctation. Unrepaired coarctation will
Clinical Manifestations result in persistent hypertension and subsequent left
This mechanical obstruction to blood in the ventricular hypertrophy, which could place patients
descending aorta diverts blood flow through the at risk of arrhythmias and left ventricular failure.
innominate (or brachiocephalic), left carotid, and The risks of a coarctation operation are somewhat
left subclavian arteries. This results in a difference less than those of other heart surgeries because this
in systolic blood pressure between the upper and the procedure can be performed without using cardiopul-
lower extremities. Blood pressure measured in the monary bypass. Operative mortality is less than 1%
upper extremities is at least 10 mm Hg higher than (20). Patients usually do well postoperatively, but are
systolic blood pressure in the lower extremities. at risk for the following complications:
Older patients may be asymptomatic (which some-
times delays diagnosis) or may present with chest • Persistent hypertension: Residual hypertension
pain with exercise or cool extremities that are after coarctation repair is thought to be due to
painful during physical activity. an upregulation of the renin-angiotensin-aldos-
On clinical exam, patients may exhibit the terone system that occurs from reduced blood
following: flow to the kidneys (whose blood supply is distal
to the coarctation segment).
• Diminished or absent femoral pulses • Vocal cord paresis or paralysis: Vocal cord pare-
• Brachiofemoral delay (a delay occurs between sis can occur secondary to injury to the recur-
the occurrence of the brachial pulse and the rent laryngeal nerve, which loops around the
femoral pulse) thoracic aorta near the coarctation site. This is
• Continuous flow murmur detected from the important to remember if the postoperative
presence of collateral vessels patient demonstrates evidence of upper airway
Some neonates will have such severe coarctation obstruction (stridor) or hoarseness.
that their systemic perfusion is dependent on flow • Chylothorax: Injury to the thoracic duct, a
through the ductus arteriosus. When the ductus thin vessel that empties lymph from the entire
closes, these infants may present with shock (inade- body into the internal jugular vein, results in
quate perfusion as a result of extremely low blood the accumulation of chyle into the pleural
pressure) and cardiovascular collapse. space, known as a chylothorax. This can
EKG and chest radiograph findings are usually present as respiratory distress with a pleural
normal in young children. Over time, children may effusion on chest radiograph.
develop left ventricular hypertrophy visible on • Lower extremity paralysis: The greater spinal
EKG results. Rib notching, which appears as con- artery, a branch of the descending aorta, sup-
cave irregularities on the inferior rib surface from plies the anterior portion of the spinal cord
dilated intercostal vessels, may be evident on chest starting at the T10 level. Because the aorta must
radiograph. be cross-clamped during the repair, blood flow
Diagnosis is usually determined through echocar- to the arterial branches distal to the clamps is
diography and magnetic resonance imaging (MRI). halted for the time it takes to perform the
repair. This can result in ischemia to the spinal
Management and Treatment cord if the cross-clamp time is lengthy.
A coarctation of the aorta is repaired surgically by a • Postcoarctectomy syndrome: This usually
left thoracotomy incision. The coarctation segment is occurs in patients who have had coarctation for
removed by the surgeon, and the aorta is reconnected several years prior to repair. It is caused by
in an end-to-end fashion. Alternatively, a homograft reperfusion injury to the intestines and presents
segment or Dacron patch may be placed between the with severe abdominal pain, nausea, and some-
two aortic segments if the distance between them is times bloody stools. Symptoms usually improve
significant. Patients with no other cardiac lesions usu- with aggressive management of hypertension
ally do not need cardiopulmonary bypass for this type and avoiding oral intake for a few days.
of procedure. An alternative to surgical repair is per- Some patients can develop recoarctation that
forming a balloon angioplasty (dilation and widening necessitates an intervention (e.g., balloon dilation,
2831_Ch11_261-278 13/03/14 3:34 PM Page 273
aortic arch. Children diagnosed with double aortic kids, so she took her in for an evaluation at the
arch should be immediately referred for surgical re- pediatrician’s office. On clinical examination, the
pair. During surgery, the nondominant left aortic pediatrician noted a systolic ejection murmur as
arch is divided and ligated, leaving the dominant well as a fixed split of the second heart sound. An
right aortic arch intact. This effectively relieves the echocardiogram revealed a 5-mm secundum atrial
airway obstruction. However, children may continue septal defect. Today Jane went to the operating
to have airway symptoms, such as wheezing or mild room for patch closure of the ASD. She was just
stridor, for several months following the operation. extubated at the bedside in the intensive care unit
and is now recovering. Her pulse oximeter is
Course and Prognosis currently reading 87%.
In the neonate, double aortic arch can result in
• You are the RT caring for her; what conditions
critical upper airway obstruction and death if
could cause hypoxemia in the postoperative
not managed appropriately. Prognosis is excellent
period?
following repair, and intraoperative mortality is al-
• What therapies should you initiate?
most zero (15). It is important to remember that
• What would you do if the oxygen saturations
some patients may continue to have symptoms for
continued to decrease?
several months after surgical repair. Because of
compression from the aortic arch, the tracheal carti- ■ Case 2: Tyrone Dramel
lage may not develop appropriately (23). This may Tyrone Dramel is a 2-month-old male with Down
cause tracheomalacia, a “softening” of the tracheal syndrome (trisomy 21) who is presenting to the
cartilage that results in collapse during inspiration emergency department with respiratory distress.
and manifests as inspiratory stridor or wheezing, His mom describes that, since birth, he has had
depending on the affected site. Children with signifi- trouble feeding and has not gained very much
cant tracheomalacia may require positive pressure weight. If he eats for too long, he becomes
ventilation (delivered either noninvasively or by sweaty, irritable, and sometimes turns blue around
endotracheal tube), especially during a concomitant the mouth. On examination, Tyrone has no fever,
illness, to overcome airway collapse. There is no but is breathing very rapidly. You hear scattered
specific therapy, except supportive, for tracheomala- wheezing and a few crackles at the bases. You
cia. It will improve as the child grows. also detect a loud, holosystolic murmur.
• What types of congenital heart disease could
■ ■ CJ’s respiratory panel is positive for rhinovirus. cause this patient’s symptoms?
An echocardiogram obtained in the emergency • How would you make the diagnosis?
department reveals a large, unrestrictive perimem-
branous VSD with left-to-right shunting. The baby is ■ Case 3: Baby Girl (BG) Mack
admitted to the cardiology service where she is You are an RT for a transport program, transport-
treated with oxygen and a dose of furosemide. She ing a neonate, BG Mack, with critical aortic steno-
is scheduled for a repair in 6 weeks, once her con- sis to the nearest children’s hospital. BG Mack
current infection has resolved. was born at 38 weeks’ gestation earlier today
and was noted to have cyanosis and hypotension
shortly after birth. Echocardiography revealed
critical aortic stenosis and BG Mack was initiated
■■ Critical Thinking Questions: Carly on a PGE1 infusion to keep the ductus arteriosus
Jo Johnson patent.
1. What is the cause of the presentation of hypox-
• What is a major side effect of PGE1 that could
emia in CJ Johnson?
cause problems during transport?
2. Why is it important to know this?
• How is this side effect managed?
■ Case 4: Martin Gantt
Martin Gantt is an 8-year-old male admitted to the
◗● Case Studies and Critical pediatric floor for progressive fatigue and “turning
Thinking Questions blue” while playing soccer. An echocardiogram
revealed moderate pulmonic valve stenosis.
■ Case 1: Jane Mercer • What would you expect to hear on clinical
Jane Mercer is a 5-year-old female recently examination?
adopted from China. Her mom noticed that she • What do you suspect Martin’s chest radi-
seemed to tire easily when playing with the other ograph shows?
2831_Ch11_261-278 13/03/14 3:34 PM Page 275
Multiple-Choice Questions
1. The two most common types of acyanotic c. Wheezing
heart defects are: d. Pneumothorax
a. ASD and VSD 6. A 4-month-old baby is admitted to the hospital
b. VSD and pulmonic stenosis by her primary pediatrician for poor growth
c. Aortic stenosis and pulmonic stenosis and a heart murmur. Her EKG shows left
d. Coarctation of the aorta and double atrial enlargement and left ventricular hyper-
aortic arch trophy, chest radiograph is significant for
2. Which of the following techniques is used as cardiomegaly and pulmonary edema, and SpO2
definitive diagnosis of a cardiac defect? is 95%. When you auscultate, you note a soft
a. Auscultation holosystolic murmur, loudest at the fourth in-
b. Chest radiograph tercostal space. What acyanotic heart defect do
c. Electrocardiogram you suspect this infant has?
d. Echocardiogram a. ASD
3. Which of the following acyanotic heart defects b. VSD
usually happens in conjunction with other c. Pulmonic stenosis
types of congenital anomalies? d. Aortic stenosis
a. ASD 7. A baby is diagnosed with a systolic murmur
b. VSD with an ejection click. He is referred to a cardi-
c. Double aortic arch ologist, who diagnoses aortic valve stenosis on
d. All of the above echocardiogram. At his 6-week follow-up
4. Upon auscultation, which of the following appointment with the cardiologist, his obstruc-
acyanotic defects would present with a tion is determined to be severe, with some mild
murmur? hypertrophy of the left ventricle; he also has
a. AV septal defect poor feeding and failure to gain weight effec-
b. Aortic stenosis tively since he came home from the hospital.
c. Coarctation of the aorta What is a reasonable next step in this baby’s
d. They would all present with a murmur management?
a. Continue to monitor
5. Acyanotic heart defects can often mimic b. PGE1 therapy
pulmonary disease. Which of the following c. Valvuloplasty
symptoms would not be found associated with d. Valvotomy
acyanotic heart defects?
a. Pulmonary edema
b. Stridor
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Chapter 12
279
2831_Ch12_279-306 13/03/14 3:33 PM Page 280
Chapter Objectives
After reading this chapter, you will be able to:
1. Identify the common types of cyanotic heart defects diagnosed in children.
2. Discuss the general evaluation of a neonate suspected of having a cyanotic heart defect.
3. Explain how to perform a hyperoxia test.
4. Define the two components of Ebstein anomaly.
5. List the four types of total anomalous pulmonary venous return and the two broad ways neonates can
present.
6. Describe transposition of the great arteries and describe how a neonate will present immediately
after birth.
7. Describe an atrial septostomy and in what patient population it is indicated.
8. Define the lesions associated with tetralogy of Fallot and the two ways infants can present.
9. Describe hypoplastic left heart syndrome.
10. Describe the three stages of surgical intervention for hypoplastic left heart syndrome.
11. Describe the benefits and risks of using hypoxic gas mixtures for infants with cyanotic heart defects.
12. State the indications for a prostaglandin E (PGE) infusion for newborns.
13. Define truncus arteriosus and describe how a neonate will present.
■■ Mia Mcnamara beyond the scope of this text. The diseases included
in the text are chosen because of the relative fre-
quency with which they are diagnosed, the impor-
You are working in a 200-bed children’s hospital that
tance of rapid diagnosis and initial treatment, or the
serves an extensive rural population. You are assist-
implications of anatomy and presentation of the
ing in the triage area of the emergency department
defect to respiratory management.
when the nurse asks you to help her look at Mia,
In the United States, where children receive very
a 6-month-old baby brought in by her mom. Her
close monitoring and frequent health care in infancy,
mother tells you and the nurse that at 4 months and
cyanotic heart disease may present immediately after
6 months, Mia was seen by her pediatrician who
birth or within the first few months of life. In coun-
noted a “strong heart murmur.” At the 6-month ap-
tries with less-established health-care systems, cyan-
pointment, he recommended consultation with a
otic heart disease may not be recognized until later
pediatric cardiologist, and though one is scheduled,
in childhood or early adulthood.
it’s not for another 6 weeks. Mom has come in today
Any neonate who presents with oxygen satura-
because Mia has had a few episodes of irritability,
tions less than 85% to 90% should be assessed to de-
becoming agitated and inconsolable, and her face
termine whether the cause of the hypoxemia is lung
and lips turn blue.
disease or congenital heart disease. Evaluative meas-
ures include chest radiograph, electrocardiograph,
hyperoxia test, and echocardiogram; auscultation
A
s Chapter 11 discussed, the structural abnor- may often reveal abnormal heart sounds, but normal
malities that lead to the diagnosis of congen- findings are not conclusive (see Table 12-1). Certain
ital heart disease can be divided broadly into therapeutic measures, such as prostaglandin E1
acyanotic or cyanotic congenital heart disease. This (PGE1) and oxygen delivery, may be warranted
chapter focuses on cyanotic heart defects, which re- while diagnostic procedures are being completed.
sult from structural abnormalities that lead to sig- A chest radiograph should be taken to assess the
nificant mixing of oxygenated and deoxygenated lung fields and heart size. An electrocardiograph
blood and cause oxygen saturations of less than (ECG) should be obtained, but the results will fre-
85%. This chapter will discuss several of the more quently be normal. A normal result should not rule
common cyanotic defects, including tetralogy of out the presence of congenital heart defect.
Fallot, total anomalous pulmonary venous return, A hyperoxia test should also be performed, in
transposition of the great arteries, hypoplastic left which arterial blood gases are obtained on room
heart syndrome, Ebstein anomaly, and truncus arte- air and 1.0 fractional concentration of inspired
riosus. There are many variations of cyanotic heart oxygen (FIO2) and compared to assess a patient’s
defects, and a description of all abnormalities is ability to oxygenate. To start, a baseline arterial
2831_Ch12_279-306 13/03/14 3:33 PM Page 281
blood gas (ABG) is obtained from the right radial cyanotic heart defect is suspected, the neonate
artery while the patient is breathing room air. should be referred to a tertiary care center for fur-
Obtaining the blood gas from the right radial ther evaluation and management by intensivists
artery is critical to avoid misinterpretation of and cardiologists.
oxygenation ability because of the neonate’s patent For any neonate presenting with cyanosis, an
ductus arteriosus (PDA), through which shunting intravascular infusion of prostaglandin E (PGE)
of blood occurs. The PDA connects the pulmonary should be started. Prostaglandins are hormone-like
artery to the aorta near the origin of the left sub- substances that perform a variety of functions
clavian artery. As described in Chapter 2, the PDA in the body. PGE1 will maintain patency of the
is necessary for intrauterine fetal circulation and PDA and allow mixing of oxygenated and deoxy-
usually closes over the first few days of life. A right genated blood. Once the specific cardiac lesion has
radial ABG will give an accurate measure of the been identified by echocardiogram and the presence
partial pressure of oxygen in the blood (PaO2), of any additional shunts (e.g., patent foramen ovale
directly from the aorta, before the point at which [PFO], ventricular septal defect [VSD], or atrial
a PDA may mix deoxygenated blood in aorta and septal defect [ASD]) has been verified, PGE may be
decrease PaO2. After a baseline ABG is obtained, discontinued.
the patient then should be placed on FIO2 1.0 Echocardiogram is the gold standard for diagno-
using an oxyhood or non-rebreather mask. Ten to sis and differentiation of congenital cardiac malfor-
15 minutes later, a repeat ABG is obtained from mations. An echocardiogram uses ultrasound to
the right radial artery. If the PaO2 of the sample assess the anatomy of the heart, normal and abnor-
on FIO2 1.0 is higher than 150 mm Hg, the hypox- mal patterns of blood flow, and blood pressures at
emia is likely related to lung disease, such as pneu- various places within the heart. This test is com-
monia or respiratory distress syndrome. If the pleted by a cardiologist, usually at the bedside, and
PaO2 is lower than 150 mm Hg, a cyanotic heart the information obtained is important for the res-
defect should be suspected because the low PaO2 piratory therapist (RT) to understand because it
likely is due to shunting and mixing of oxygenated will provide information regarding expected pul-
and deoxygenated blood. Despite a delivered FIO2 monary blood flow and acceptable SpO2 ranges,
of 1.0, the complete blood mixing prevents the and it may have implications on ideal blood gas
PaO2 from rising above an expected level. Once a values.
2831_Ch12_279-306 13/03/14 3:33 PM Page 282
■ ■ Mia looks comfortable resting in her mother’s lap (vertebral, anal, cardiac, tracheoesophageal, renal
and does not seem agitated. Her respiratory rate and limb abnormalities) (3).
(RR) is 35 breaths/min. You place a pulse oximeter
on Mia, and her arterial blood oxygen (SpO2) is 88%, Pathophysiology
with a pulse rate of 145 bpm. You place Mia on a The anatomy of TOF centers on four components
nasal cannula and call the pediatrician to the bedside of intracardiac anatomy:
for a consultation.
The pediatrician listens to the heart and notes
• A large malaligned, unrestrictive VSD in the
a harsh systolic ejection murmur along the left ster-
membranous portion of the septum that al-
nal border and normal breath sounds. She orders
lows flow of blood between the left and right
a 12-lead EKG, chest radiograph, hyperoxia test,
ventricles
echocardiogram, and cardiology consultation.
• An aorta that straddles or “overrides” the
You remove the nasal cannula and return 20 minutes
VSD so that blood from both ventricles may
later and obtain a right radial ABG. Results are pH,
enter the systemic outflow tract
7.38; PaCO2, 44 mm Hg; PaO2, 56 mm Hg; HCO3,
• A fixed or variable degree of right ventricular
25.7 mEq/L. You place Mia on a non-rebreather
outflow tract obstruction (RVOTO) at or adja-
mask at 15 LPM, and her SpO2 increases to 100%.
cent to the pulmonary valve, which causes a
You return 15 minutes later and draw another ABG.
decrease in pulmonary blood flow
The results are pH, 7.44; PaCO2, 36 mm Hg; PaO2,
• Right ventricular hypertrophy as a result of
110 mm Hg; HCO3, 24.1 mEq/L. Based on these
the RVOTO
results, you are reasonably sure that Mia has some Other pulmonary artery pathology may be pres-
type of cyanotic heart disease. ent, leading to variations in pathophysiology and
clinical course (Clinical Variation 12-1).
The degree of RVOTO and the relative resistance
of the systemic and pulmonary vasculature deter-
Tetralogy of Fallot mine TOF pathophysiology. Cyanosis is directly
proportional to the amount of blood being shunted
Tetralogy of Fallot (TOF) (Fig. 12-1) is caused by a as a result of RVOTO. If there is mild obstruction,
combination of four conditions: VSD, an aorta that patients may have no clinical manifestations. On the
overrides the VSD, obstruction of the right ventric- opposite end of the spectrum, infants may present
ular outflow tract, and right ventricular hypertrophy in the neonatal period with severe RVOTO and
(1). It is the most common form of cyanotic congen- cyanosis due to severe pulmonary stenosis or pul-
ital heart disease, representing 3.5% of all infants monary atresia leading to shunting of deoxygenated
with congenital heart disease and 4.05 per 10,000 live blood from the right ventricle to left ventricle and
births (2). In addition to this classic intracardiac aorta. These infants may require early treatment to
pathology, other forms of TOF include pulmonary provide pulmonary blood flow with a PGE1 infusion
artery or other cardiac abnormalities. TOF may be
associated with genetic abnormalities such as tri-
somy 21, 22q11 deletion, and VACTERL syndrome
Clinical Variations 12-1
Variations of TOF
In addition to the four main components of TOF, there
may be additional pulmonary valve abnormalities.
Aorta
These can include an absent or dysplastic pulmonary
Left atrium
valve with regurgitation, pulmonary artery stenosis, or
Hypoplastic pulmonary valve atresia. These can all put additional
Right pulmonary
artery
strain on the right heart and lead to right ventricular
atrium
Abnormally hypertrophy, and may also increase blood flow dys-
Stenotic
pulmonary positioned function to the pulmonary artery, leading to poor
valve aortic valve oxygenation.
Right
VSD Another variation is known as “pink tet,” in which
ventricle Left patients may have no cyanotic symptoms because
ventricle SVR transmitted to the right ventricle via the VSD
overcomes the mild RVOTO and provides pulmonary
blood flow (4).
Figure 12-1 Tetralogy of Fallot
2831_Ch12_279-306 13/03/14 3:33 PM Page 283
Management and Treatment It also allows for completion of the repair in one
operation. However, there are concerns that patients
Many cases of TOF are diagnosed prenatally. Initial
with TOF repaired in infancy may need reoperation
management of the newborn involves assessing the
later in life for residual RVOTO or pulmonary re-
infant using a physical examination and echocardio-
gurgitation associated with valve incompetency.
graphy. If pulmonary blood flow is critically limited
Proponents of the BT shunt prior to complete repair
by severe RVOTO or pulmonary atresia, duc-
argue that shunting provides reliable pulmonary
tal patency may need to be maintained with
blood flow until the child is bigger (typically 3 to
PGE1 infusion until palliation or repair can be un-
6 months of age). Repair at that time may be more
dertaken in the first days of life.
successful and ultimately make reoperation less
Infants who have insignificant RVOTO and are
likely (Evidence in Practice 12-1).
not cyanotic may be discharged home for feeding
Outcomes from TOF repair are very good, with
and growing in anticipation of surgical repair in the
mortality rates less than 10% in most reports. Data
first few months of life. They may forego surgery
show there is 90% long-term survival even in patients
until they either have progressive cyanosis or until
who had the earliest repairs in the 1950s (excluding
they have reached appropriate size and weight for
hospital mortality) (8). In a large retrospective study
primary repair.
of a single center’s experience with 570 TOF repairs
Infants who have intermittent tet spells may require
over 50 years, early and late mortality was low
initial medical management to decrease cyanosis.
at 7%, with no early mortality reported in the last
Acute spell management includes oxygen, knee-
10 years. Risk of reoperation increased linearly with
to-chest maneuvers, medications to increase
time in both primary repair and palliation (9).
SVR (e.g., phenylephrine), volume administration
Late complications are common after TOF repair.
to increase flow into the pulmonary vasculature,
RVOTO can recur and cause right ventricular hy-
and sedatives such as morphine to decrease cate-
pertension and need for reoperation. It is common
cholamines and perhaps decrease spasm at the open-
for repaired TOF patients to develop right ventricu-
ing of the pulmonary valve. In patients who cannot
lar dilation and dysfunction that is thought to be due
undergo surgical repair, use of propranolol has been
to the accumulated effects of right ventricular hyper-
found to decrease the frequency of tet spells by de-
tension with RVOTO, cardiopulmonary bypass, and
creasing heart rate, hypercontractility, and relaxing
perhaps intrinsic myocardial dysfunction. Addition-
the RVOTO.
ally, techniques for right ventricular outflow tract
Surgical repair of TOF involves the following:
repair often distort the pulmonary valve, causing
• providing relief of RVOTO pulmonary regurgitation and need for pulmonary
• complete separation of atria and ventricles valve replacement later in life, often via a right ven-
• preservation of pulmonary valve and tricuspid tricle to pulmonary artery conduit or channel. Some
valve function patients need repeat operations for conduit stenosis
or symptomatic regurgitation. In one review of adult
This involves closure of the VSD, resecting the
patients who had repair in childhood, half had the
obstructions above and below the pulmonary valve,
and/or pulmonary valve repair. This surgery is typ-
ically performed from the right atrium through the
tricuspid valve, although transventricular repair ● Evidence in Practice 12-1
has been used. Full surgical repair can be techni- Early Versus Staged Repair for TOF—
cally difficult in neonates and small infants who re-
quire surgical intervention; therefore, some centers One Hospital’s Experience
offer initial improvement of symptoms using a In 2000, the Hospital for Sick Children in Toronto,
systemic-to-pulmonary shunt, such as a modified Ontario, reported their experience transitioning from
Blalock-Taussig (BT) shunt (discussed in the man- palliation to complete repair in neonates. During the
agement and treatment of hypoplastic left heart 1990s, the rate of palliation prior to repair fell from
syndrome discussion, below), followed by complete 38% to 0%, with a mortality rate of zero during the
repair a few months later. Infants with BT shunts last 2 years reported. However, children younger than
remain cyanotic, with oxygen saturations of 75% to 3 months of age had longer intensive care unit stays
85%, until repair. Many institutions are moving and overall hospitalizations, and the authors con-
toward earlier primary repair in infancy, which will cluded that repair after 3 months was the optimal time
decrease morbidity and mortality and the need for frame (6). Repair in children younger than 28 days of
further surgical intervention (5). age has been reported not to have increased mortality
The advantage of early repair of TOF is the or hospital length of stay, but may be associated with
avoidance of prolonged cyanosis, thus avoiding the an increased need for reintervention or reoperation (7).
risks associated with systemic-to-pulmonary shunt.
2831_Ch12_279-306 13/03/14 3:33 PM Page 285
Innominate
vein
Ascending
vein
Superior
Pulmonary
vena cava
veins
Pulmonary Left
veins atrium
ASD
Right
atrium Left
ventricle
Right
ventricle
Inferior
vena cava
Supracardiac TAPVR
2. TAPVR to the coronary sinus (intracardiac) blood cannot get to the left side of the heart
occurs when the pulmonary vein confluence and death would occur.
drains directly into the coronary sinus, which
Key to the understanding of TAPVR and its
is the structure responsible for venous return
course is the possibility of obstruction within the
from the myocardium. The coronary sinus
pulmonary venous pathways to the right atrium. Ob-
drains into the right atrium.
struction may occur at the level of the atrial septum,
3. Infracardiac TAPVR occurs inferior to the
the vertical veins, or the ductus venosus. Obstruction
heart, and the pulmonary vein confluence sits
is most common in infracardiac TAPVR because the
posterior to the left atrium. A descending ver-
ductus venosus naturally constricts and closes after
tical vein drains from the confluence below the
birth. The clinical implication of obstruction is dis-
diaphragm to the portal vein, hepatic veins,
cussed in more detail in the pathophysiology section.
inferior vena cava, or ductus venosus, which
then eventually drain into the right atrium.
4. Mixed-type TAPVR is a combination of the Pathophysiology
first three types, in which some pulmonary The abnormal anatomy of TAPVR results in left-to-
veins drain to one site and the remainder to right shunting, requiring that mixed blood shunts
another. For example, two veins may drain again from the right side to the left side of the heart.
to the right superior vena cava, whereas All oxygenated blood, which normally should fill the
the remaining two veins drain to the right left side of the heart, is delivered to the right side of
atrium. the heart, mixing with deoxygenated blood draining
5. All types of TAPVR have an ASD or PFO as into the right atrium from the inferior and superior
part of the anomaly; otherwise, oxygenated vena cavae, and then must cross the atrial septum to
2831_Ch12_279-306 13/03/14 3:33 PM Page 287
the cardiac silhouette and the parallel great vessels support to maintain a cardiologist-defined SpO2
above; however, this is not universally noted on range. Because oxygenated and unoxygenated blood
patients with TGA and intact ventricular septum. will always mix in these patients, normal SpO2 is not
There may be prominent pulmonary vascular mark- usually expected.
ings and pulmonary edema if a VSD is present. The preferred surgical repair for TGA is the
An echocardiogram should be done immediately arterial switch operation, which was first described in
in patients who present with TGA to delineate the 1975 (20). Prior to the arterial switch operation,
exact diagnosis and associated lesions. The relation- TGA was repaired by baffling or tunneling the atria.
ship of the aorta to the pulmonary artery, the size of This would cause systemic venous return to flow to
the PFO or ASD, the presence of a VSD and PDA, the left side of the heart and out the pulmonary
left ventricular outflow tract obstruction, aortic arch, artery, and the pulmonary venous return to course
and coronary artery pattern must all be determined. to the right side of the heart and out the aorta. One
of the long-term problems with this approach has
Management and Treatment been that the right ventricle is still the systemic ven-
For a neonate with TGA and severe cyanosis from tricle, being forced to pump against SVR. The right
inadequate mixing, an intracardiac shunt must be ventricle was not designed to withstand this large
created immediately so that the infant will survive. amount of pressure, and thus the patient will develop
An atrial septostomy (also known as a Rashkind pro- right ventricular failure over time. In the arterial
cedure) is performed, usually at the patient’s bedside. switch operation, the aorta and pulmonary artery
The procedure will create a hole in the atrial wall, are returned to their normal positions. The aorta is
causing a wide-open atrial-level shunt so that mixing connected to the proximal pulmonary artery to form
can occur and saturations will stabilize. The proce- a neo-aorta, and the pulmonary artery is connected
dure is performed by an interventional cardiologist. to the proximal aorta to form the neo-pulmonary
A balloon catheter is inserted via the umbilical vein artery. The coronary arteries are excised from the
or femoral vein and threaded through the inferior aortic sinus and reimplanted into the neo-aortic
vena cava into the right atrium. Using echo guidance, root. If a VSD is present, that is closed as well. Stud-
the catheter is manipulated through the atrial septum ies have shown that outcomes are better if the arte-
to cross into the left atrium (Fig. 12-6). The balloon rial switch operation is done early in the neonatal
is then inflated and pulled back rapidly across the period (21, 22). It is important to note that the arte-
atrial septum into the right atrium. Saturations rial switch needs to be done before the left ventricle
should rise immediately after this hole is created and has had time to weaken, when it is still able to toler-
blood from the right and left heart mix. Complica- ate SVR. If surgery is delayed, the left ventricle needs
tions of an atrial septostomy include tearing of the to be retrained to contract against the higher SVR
atrial wall, pulmonary veins, or inferior vena cava, with staged maneuvers such as pulmonary artery
as well as atrioventricular valve damage. Emergency banding before surgically attaching the aorta to the
surgery may be required if any of these complications left ventricle so that left ventricular failure does not
occur. occur after the arterial switch.
Once the atrial septostomy is performed, the
patient can be stabilized prior to surgical re- Course and Prognosis
pair. The RT’s role at this point is usually to Operative mortality for the arterial switch operation
support ventilation as needed and provide oxygen is less than 10% (23, 24). Early complications after
the operation are usually the result of myocardial is-
chemia (lack of blood flow to the heart muscle) from
abnormalities of the reimplanted coronary arteries.
Myocardial ischemia can occur from the following:
• impingement or obstruction of a coronary by
surrounding structures
• a tortuous (winding or complex) course caused
by repositioning of the coronary artery; this
may also include kinking of the coronary ar-
tery, which can slow or block blood flow
• stenosis at the connection site of the coronary
artery to the neo-aorta
Long-term complications include several progres-
sive abnormal anatomical findings at the surgical
Figure 12-6 Atrial Septostomy Procedure sights. One of these is supravalvar stenosis, which is
2831_Ch12_279-306 13/03/14 3:33 PM Page 291
A
B C
neo-aorta and to provide pulmonary blood flow via (Evidence in Practice 12-3). This alternative tech-
a systemic-to-pulmonary shunt. This procedure is nique is known as a Sano modification.
complex and has significant risk; mortality is re- After stage 1 in the neonatal period, infants are
ported to be from 10% to 20% (27, 28). In an effort managed until stage 2 reconstruction is attempted,
to identify patents most at risk for mortality after typically at 4 to 6 months of life. Mortality between
stage 1, one study noted risk factors included pre- stages 1 and 2 is generally reported to be 10%, mak-
maturity, restrictive intra-atrial septum, longer car- ing overall mortality before stage 2 for children with
diopulmonary bypass time, weight less than 2.8 kg, HLHS approximately 20% (27, 28).
revision of the systemic-to-pulmonary shunt, and
postoperative extracorporeal membrane oxygena- Stage 2: Bidirectional Glenn Procedure
tion (ECMO) (27). Stage 2 reconstruction, known as the bidirectional
Modifications of this classic procedure include a Glenn (BDG) procedure, changes pulmonary blood
right ventricle to pulmonary artery (RV-PA) con- flow to a passive flow or drainage system, which con-
duit for pulmonary blood flow rather than the nects the superior vena cava to the pulmonary artery
modified BT shunt; this RV-PA conduit was origi- and bypassing the right heart. The systemic-to-
nally proposed by Norwood, but initial attempts pulmonary shunt placed in stage 1 is removed. BDG
were unsuccessful. Sano and colleagues reintro- requires low pulmonary vascular resistance to ensure
duced a modified version of Norwood’s classic passive blood flow from the superior vena cava to
RV-PA conduit in 1983 (29), although the benefit the pulmonary artery; therefore, a cardiac catheter-
of one technique over the other is still unproven ization is performed before the BDG procedure to
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Wolff-Parkinson-White syndrome
Wolff-Parkinson-White syndrome (WPW) is one of
several disorders of the conduction system of the
heart that are commonly referred to as pre-excitation
syndromes. WPW is caused by the presence of an
abnormal accessory electrical conduction pathway
between the atria and the ventricles. Electrical signals
traveling down this abnormal pathway stimulate the
ventricles to contract prematurely, resulting in a
supraventricular tachycardia referred to as an atri-
oventricular reentrant tachycardia. Figure 12-11 Chest Radiograph of Newborn with
Ebstein Anomaly (Courtesy of Jane Benson, MD)
2831_Ch12_279-306 13/03/14 3:33 PM Page 298
and the pulmonary artery. If anatomical pulmonary secondary to significant tricuspid regurgitation. Pa-
atresia is present, surgical intervention, such as the tients with atrial fibrillation or atrial flutter may need
placement of a Blalock-Taussig shunt (BT shunt), to be treated with cardioversion acutely and then
is needed. Patients with BT shunts are followed with anti-arrhythmics.
over the first 6 to 12 months until they begin to out-
grow the shunt and require more long-term surgical Course and Prognosis
palliation (treatment to improve symptoms), which Most patients with Ebstein anomaly survive into
may include Glenn and Fontan procedures, com- adulthood. One study reported that 1-year survival
pleted over several stages (see Table 12-2). In the was 67% and 10-year survival was 59% (44). This
Glenn procedure, the superior vena cava is con- study showed a shortened life span, with few pa-
nected directly to the pulmonary artery, and in the tients living past 70 years of age. Mortality rates are
Fontan procedure, the inferior vena cava is con- higher for neonatal patients requiring early inter-
nected to the pulmonary artery (see Fig. 12-9). These vention (45). Those with a mild form of the disease
procedures allow venous blood to bypass the right may live a normal life span. Outcomes are worse
heart and travel to the lungs for oxygenation and with more severe tricuspid valve displacement and
allow permanent separation of the pulmonary and regurgitation and right ventricular hypoplasia and
systemic circulations. dysfunction. For patients who require intervention,
The decision to repair the tricuspid valve—either one large study reported age at surgery between
with primary repair of the valve or placement of a 2 months and 79 years, with a median age at opera-
prosthetic valve, as discussed in Chapter 11—or to tion of 20 years (46). Thirty-four percent underwent
proceed with the Glenn or Fontan procedures after valve repair, and 66% underwent tricuspid valve re-
a BT shunt depends on the size of the patient, the placement. Approximately 5% of all patients who
size of the right ventricle, presence of anatomical underwent intervention experienced early death,
pulmonary atresia, and the anatomy of the tricuspid and 7.6% experienced late death over 25 years of
valve. There are specific indications for surgery: follow-up. Another study from the same institution
reported that for those who required surgery, 82%
• Increased right heart size
required no further intervention at 10 years’ follow-
• Right ventricular dysfunction
up, and 56% required no further intervention at
• Dyspnea
20 years’ follow-up (47). Nearly 80% were reported
• Exercise intolerance
to have an excellent or good outcome, and more
• Ventricular or atrial tachyarrhythmias not
than half of the study group was free of cardiac
controlled by medical therapy or catheter in-
symptoms, including arrhythmias.
tervention
• Significant associated cardiac lesions
Truncus Arteriosus
Neonates who do not need medical intervention
will be followed long-term by a pediatric cardiolo- Truncus arteriosus (Fig. 12-12) is a condition in
gist. These patients may grow and develop normally which a single great vessel leaves the heart and sup-
until symptoms such as cyanosis and right heart fail- plies the systemic and pulmonary circulation. The
ure develop in adolescence or early adulthood. If prevalence of truncus arteriosus is estimated to be
tricuspid regurgitation is increasing in severity, tri- 0.74 per 10,000 live births (2).
cuspid valve repair or replacement may be indicated.
Heart transplantation is also an option for patients
with biventricular dysfunction in which repair is
thought unlikely to be successful. For patients with Aorta
heart failure, inotropes (medications to improve car- Pulmonary
diac contractility) may be necessary to stabilize the Superior vein
vena cava
patient’s blood flow. Once the patient is clinically
stable, conversion to long-term heart failure medica- Left
Truncus atrium
tions (e.g., diuretics and digoxin) is possible. arteriosus
Arrhythmias may develop in children with Ebstein Right
anomaly at any time. Supraventricular tachycardia atrium VSD
(SVT) may be present after birth or it may develop Right Left
ventricle ventricle
later and be resistant to medical therapy or be well
controlled on anti-arrhythmics (e.g., amiodarone). Inferior
Older patients with recurrent SVT can be treated by vena cava
an electrophysiologist. Atrial fibrillation and atrial
flutter also tend to develop as atrial dilation occurs Figure 12-12 Truncus Arteriosus
2831_Ch12_279-306 13/03/14 3:33 PM Page 299
Clinical Manifestations
Truncus arteriosus may be diagnosed prenatally
after routine ultrasound screening for anom- Figure 12-13 Chest Radiograph of Neonate with Truncus
alies. Neonates without prenatal diagnosis Arteriosus (Courtesy of Jane Benson, MD)
2831_Ch12_279-306 13/03/14 3:33 PM Page 300
remains the basis of the treatment of this condition ■ ■ Mia remains in the PICU until surgical repair of
today. her TOF can be scheduled. She remains on oxygen
Without surgical intervention, mortality with as needed to keep her SpO2 greater than 80% per
truncus arteriosus is high. Although earlier tech- the echocardiogram, but she is able to be maintained
niques involved delayed repair until a few months of on room air for most of her presurgical course, re-
life or even palliation of truncus arteriosus with quiring supplemental oxygen only during tet spells,
banding of one or more pulmonary arteries, repair along with knee-to-chest maneuvers, which seem to
of truncus arteriosus in the neonatal period is now be very successful. Two days later, she is taken to
the standard. The surgical goals are to achieve the the OR for complete repair, including VSD repair and
following: relief of RVOTO. She returns to the PICU after sur-
gery, where she is on the ventilator postoperatively
• Isolate pulmonary blood vessels from the
for 1 day before being successfully extubated to
truncus
room air.
• Provide continuous connection of the pul-
monary arteries to the right ventricle, which
is typically done by a right ventricle to pul-
monary artery (RV-PA) conduit. ■■ Critical Thinking Questions:
• Close the VSD. Mia Mcnamara
• Repair or replace the truncal valve if regurgi-
1. What type of postoperative ventilatory support
tant or stenotic.
would you have recommended for Mia?
While awaiting surgery, excessive pulmonary 2. What do you expect Mia’s postsurgical respiratory
blood flow and congestive heart failure may need to therapy needs will be?
be managed with diuretics. Respiratory management 3. If a knee-to-chest maneuver had not been suc-
is supportive, and involves pre- and postoperative cessful at relieving Mia’s hypoxemia, what other
ventilation support for cardiac and respiratory fail- treatments could have been implemented?
ure, and oxygen therapy as needed to maintain SpO2
75% to 85%.
Course and Prognosis ◗● Case Studies and Critical
In the early era of truncus arteriosus repair (1980s–
1990s), mortality was high at nearly 50% (51). More Thinking Questions
recently, early postoperative mortality for infants
undergoing truncus arteriosus repair has been re- ■ Case 1: Baby Girl (BG) Kelly
ported to be 5%. Lower weight at repair (less than You are working in a level 3C NICU when you are
2.5 kg), longer intraoperative cardiopulmonary by- a notified that there is a 40-week female, now
pass times, and associated interrupted aortic arch are 3 hours old, who is being admitted to the NICU
risk factors for mortality (49, 51). from the well-baby nursery. Her mother had an
Early complications of truncus repair include uneventful pregnancy and vaginal delivery. A few
need for early reoperation such as reexploration hours after birth, the baby was noted to be dusky.
for bleeding, wound infection, chylothorax, and ar- When the nurse checked her vitals, her heart rate
rhythmias. Delayed sternal closure is common. was 165 bpm, her respiratory rate 60 breaths/min,
Long-term mortality has been reported to be 5% blood pressure 65/38 mm Hg, and saturations
to 10%, with increased mortality in patients who are 80% on room air. She was placed on oxygen, and
small at the time of repair or in those who require the NICU was contacted for transfer. On arrival,
truncal valve replacement. Reoperation for replace- she is visibly cyanotic, with saturations of 70%
ment of the RV-PA conduit is common, with nearly obtained from a pulse oximeter on her right hand
half requiring this procedure by 3 years of age and and while breathing 1.0 via a non-rebreather
75% needing it by 5 to 8 years (49, 52). Additionally, mask. Her vital signs also include a heart rate
multiple long-term interventions for complications of 175 bpm, respiratory rate of 80 breaths/min,
are common. Procedures such as valve replacements and blood pressure of 60/35 mm Hg.
and balloon dilation for conduit obstruction, pul-
• What could be three causes of BG Kelly’s
monary artery obstruction, arch obstruction, or
hypoxia?
stenosis are common (51).
Advances in perioperative and surgical care have BG Kelly’s physical examination reveals cyanosis
improved outcomes in truncus arteriosus, but need and tachypnea. Her cardiac examination is notable
for reoperation and intervention to manage this for tachycardia but no murmur. Lungs are clear to
complex condition is common. auscultation. Abdomen is soft, nontender, and
2831_Ch12_279-306 13/03/14 3:33 PM Page 301
Multiple-Choice Questions
1. The most common cyanotic congenital heart a. I, II, V, I
disease found in newborns is: b. III, I, V, II, I
a. Tetralogy of Fallot. c. III, I, V, IV, I
b. Ebstein anomaly. d. V,I,III,IV,I
c. Hypoplastic left heart syndrome. 4. You are working in the pediatric emergency
d. Transposition of the great arteries. department (ED) of a community hospital,
2. Evaluation of a neonate suspected of having a and a 2-week-old infant comes in with his
cyanotic heart defect should include all of the mother. He was sent to the ED by his primary
following except: physician after his 2-week check-up because
a. Cardiac catheterization. he has had difficulty feeding and has not been
b. Hyperoxia test. gaining weight appropriately. His SpO2 on
c. Echocardiogram. pulse oximetry is 84%. On auscultation you
d. Electrocardiograph. hear a murmur, which the emergency room
e. Chest radiograph. physician describes as a fixed split S2 with an
3. Place in order the steps taken to perform a S3 gallop. The physician orders a 12-lead elec-
hyperoxia test. trocardiogram and a chest radiograph. The
I. Obtain an arterial blood gas from the EKG shows peaked P waves, and the chest ra-
right radial artery diograph shows a normal-sized heart with in-
II. Wait 15 minutes? creased pulmonary vascular markings. Based
III. Place patient on FIO2 0.21 on these findings, what is the likely diagnosis?
IV. Wait 60 minutes a. TAPVR
V. Place patient on FIO2 1.0 b. HLHS
2831_Ch12_279-306 13/03/14 3:33 PM Page 303
9. Lindberg HL, Saatvedt K, Seem E, et al. Single-center 28. Ballweg JA, Dominguez TE, Ravishankar C, et al. A con-
50 years’ experience with surgical management of tetralogy temporary comparison of the effect of shunt type in hy-
of Fallot [published online ahead of print, 2011]. Eur J poplastic left heart syndrome on the hemodynamics and
Cardiothorac Surg. doi:10.1016/j.ejcts.2010.12.065. outcome at stage 2 reconstruction. J Thorac Cardiovasc
10. Hickey EJ, Veldtman G, Bradley TJ, et al. Late risk of Surg. 2007;134:297-303.
outcomes for adults with repaired tetralogy of Fallot 29. Sano S, Ishino K, Kawada M, et al. Right ventricle-pul-
from an inception cohort spanning four decades. Eur J monary artery shunt in first-stage palliation of hypoplastic
Cardiothorac Surg. 2009;35:156-166. left heart syndrome. J Thorac Cardiovasc Surg. 2003;126:
11. Niwa K, Siu SC, Webb GD, Gatzoulis MA. Progressive 504-510.
aortic root dilation in adults late after repair of tetralogy 30. Bacha EA, Daves S, Hardin J, et al. Single-ventricle pallia-
of Fallot. Circulation. 2002;106:1374-1378. tion for high risk neonates: the emergence of an alternative
12. Lurz P, Coats L, Khambadkone S, et al. Percutaneous pul- hybrid stage 1 strategy. J Thorac Cardiovasc Surg. 2006;131:
monary valve implantation: impact of evolving technology 163-171.
and learning curve on clinical outcome. Circulation. 2008; 31. Toiyama K, Hamaoka K, Oka T, et al. Changes in cere-
117:1964-1972. bral oxygen saturation and blood flow during hypoxic gas
13. Gatzoulis MA, Balaji S, Webber SA, et al. Risk factors for ventilation therapy in HLHS and CoA/IAA complex with
arrhythmia and sudden death late after repair of tetralogy markedly increased pulmonary blood flow. Circ J. 2010;
of Fallot: a multicenter study. Lancet. 2000;356:975-981. 74:2125-2131.
14. Bertranou EG, Blackstone EH, Hazelrig JB, et al. Life 32. Gentile M. Inhaled medical gases: more to breathe than
expectancy without surgery in Tetralogy of Fallot. Am J oxygen. Respir Care. 2011;56(9):1341-1359.
Cardiol. 1978;42:458-466. 33. Walsh MA, Merat M, La Rotta, G, et al. Airway pressure
15. Kwon EN, Mussatto K, Simpson PM, Brosig C, Nugent release ventilation improves pulmonary blood flow in in-
M, Samyn MM. Children and adolescents with repaired fants after cardiac surgery. Crit Care Med. 2011;39(12):
tetralogy of Fallot report quality of life similar to healthy 2599-2604.
peers. Congenit Heart Dis. 2011;6:18–27. 34. Tibballs J, Kawahira Y, Carter BG, et al. Outcomes of
16. Reller MD, Strickland MJ, Riehle-Colarusso T, et al. surgical treatment of infants with hypoplastic left heart
Prevalence of congenital heart defects in metropolitan syndrome: an institutional experience 1983-2004.
Atlanta, 1998-2005. J Pediatr. 2008;153:807-813. J Paediatr Child Health. 2007;43:746-751.
17. Karamlou T, Gurofsky R, Al Sukhni E, et al. Factors as- 35. Rogers BT, Msall ME, Buck GM, et al. Neurodevelop-
sociated with mortality and reoperating in 377 children mental outcome of infants with hypoplastic left heart
with total anomalous pulmonary venous connection. syndrome. J Pediatr. 1995;126:496-498.
Circulation. 2007;115:1591-1598. 36. Wernovsky G, Stiles KM, Gauvreau K, et al. Cognitive
18. Kelle M, Backer CL, Gossett JG, et al. Total anomalous development after the Fontan operation. Circulation. 2000;
pulmonary venous connection: results of surgical repair of 102:883-889.
100 patients at a single institution. J Thorac Cardiovasc 37. Goldberg CS, Schwartz EM, Brunberg JA, et al. Neurode-
Surg. 2010;139:1387-1394. velopmental outcome of patients after the Fontan opera-
19. Seale AN, Uemura H, Webber SA, et al. Total anomalous tion: a comparison between children with hypoplastic left
pulmonary venous connection: morphology and outcome heart syndrome and other functional single ventricle
from and international population-based study. Circula- lesions. J Pediatr. 2000;137:646-652.
tion. 2010;122:2718-2726. 38. Ikle L, Hale K, Fashaw L, et al. Developmental outcome
20. Jatene AD, Fontes VF, Paulista PP, et al. Anatomic of patients with hypoplastic left heart syndrome treated
correction of transposition of the great vessels. J Thorac with heart transplantation. J Pediatr. 2003;142:20-25.
Cardiovasc Surg. 1976;72:364-370. 39. Mahle WT, Wernovsky G. Neurodevelopmental outcomes
21. Kirklin JW, Blackstone EH, Tchervenkov CI, et al. Clini- in hypoplastic left heart syndrome. Pediatr Cardiac Surg
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risk factors. Circulation. 1992;86:1501-1515. malformation of the tricuspid valve: genetic and environ-
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Cardiovasc Surg. 1995;109:289-302. tions and lithium use during pregnancy. Am J Psych. 1975;
23. Emani SM, Beroukhim R, Zurakowski D, et al. Outcomes 132:529-531.
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Ann Thorac Surg. 2007;84:871-878. status after operation for Ebstein anomaly: the Mayo
25. Marino BS, Wernovsky G, McElhinney DB, et al. Neo- Clinic experience. J Am Coll Cardiol. 2008;52;460-466.
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Young. 2006;16:481-489. presentation and outcome from fetus to adult. J Am Coll
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27. Pigula FA, Vida V, del Nido P, et al. Contemporary re- anomaly. J Thorac Cardiovasc Surg. 2010;139:354-358.
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Section Five
Chapter 13
Asthma
Chapter Outline Key Terms
Chapter Objectives Adrenergic
Key Terms Airway edema
Derrick Lamb Airway hyperresponsiveness
Asthma Airway remodeling
Pathophysiology Anticholinergics
Clinical Manifestations Anti-immunoglobulin E (IgE)
Management and Treatment therapy
Course and Prognosis Antileukotrienes
Critical Thinking Questions: Derrick Asthma
Case Studies and Critical Thinking Asthma action plan
Questions Asthma severity
Case 1: Amanda Peters Atopy
Case 2: Samantha Ocee Auto-positive end expiratory
Case 3: Andy Singh pressure (PEEP)
Multiple-Choice Questions Biomarkers
References Bronchoconstriction
Bronchoprovocation
Cromones
Dyspnea
Exacerbations
Exercise-induced asthma
Exhaled breath condensate
Foreign antigen
Fractional exhaled nitric oxide
(FeNO)
Heliox
Histamine
Hygiene hypothesis
Immunotherapy
Ketamine
Leukotrienes
Long-acting beta agonists (LABAs)
Magnesium
Mast cells
Methacholine
Mucus
Natural history of asthma
Peak expiratory flow (PEF)
307
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Chapter Objectives
After reading this chapter, you will be able to:
1. List the risk factors for the development of asthma.
2. Describe the four key characteristics of asthma.
3. Identify key components of the inflammatory pathway for asthma.
4. Recommend ways to identify triggers for a patient newly diagnosed with asthma.
5. Assist in obtaining a patient history for a child who wheezes and is suspected of having asthma.
6. Classify a patient’s asthma severity based on current impairment and anticipated risk.
7. Recommend daily long-term pharmacological therapy for a patient newly diagnosed with asthma.
8. Identify clinical manifestations that would require an increase or decrease in asthma therapy.
9. Diagnose a patient in status asthmaticus.
10. Recommend respiratory support for a patient with asthma and impending respiratory failure and
hypoxemia.
11. Recommend initial ventilator settings for an intubated patient in status asthmaticus.
12. Adjust ventilator settings for an intubated patient with asthma to allow adequate time for exhalation.
Derrick Lamb
recurrent episodes of wheezing, breathlessness, chest
■■ tightness, and coughing, particularly at night or in the
early morning. These episodes are usually associated
You are a respiratory therapist who works at a with widespread but variable airflow obstruction that
children’s hospital in a large urban environment. You is often reversible either spontaneously or with treat-
volunteer once a month with some of the pediatric ment. The inflammation also causes an associated
pulmonologists providing health-care outreach in the increase in the existing bronchial hyperresponsiveness
community for children without insurance. The next to a variety of stimuli. Reversibility of airflow
child in the clinic is a 7-year-old boy named Derrick limitation may be incomplete in some patients with
Lamb; you’ve met previously in the hospital’s emer- asthma (1).
gency department, where his grandmother brought
him for wheezing several times in the past year. She
has brought him to the clinic today because she Box 13-1 The National Asthma Education
says he seems to be wheezing more frequently this and Prevention Program (1)
winter season.
The National Asthma Education and Prevention
Program (NAEPP) was initiated in March 1989
to address the growing problem of asthma in the
Asthma United States. The NAEPP is administered and
Asthma is a common chronic disorder of the airways coordinated by the National Heart, Lung, and
with a complex interaction of airflow obstruction, Blood Institute (NHLBI). The NAEPP works
bronchial hyperresponsiveness, and an underlying in- with intermediaries, including major medical
flammation. A working definition of asthma has associations, voluntary health organizations, and
been commissioned by the National Asthma Educa- community programs, to educate patients, health
tion and Prevention Program (NAEPP), and is up- professionals, and the public. Every 5 years, an
dated as new evidence is uncovered (Box 13-1). The expert panel is commissioned by the NAEPP’s
NAEPP’s current definition of asthma follows: Coordinating Committee to summarize current
knowledge in asthma epidemiology, pathology,
Asthma is a chronic inflammatory disorder of the air- diagnosis, and management. The ultimate goal of
ways in which many cells and cellular elements play a the NAEPP is to enhance the quality of life for
role: in particular, mast cells, eosinophils, T lympho- patients with asthma and decrease asthma-related
cytes, macrophages, neutrophils, and epithelial cells. morbidity and mortality.
In susceptible individuals, this inflammation causes
2831_Ch13_307-354 13/03/14 3:32 PM Page 309
• Birth weight: There is a strong association in part on the timing of exposure in infancy and child-
between low birth weight and the risk of hood. Our understanding of asthma development and
physician-diagnosed asthma (13). underlying mechanisms includes the concept that gene
• Health history: The Centers for Disease Con- and environmental interactions are critical factors in
trol and Prevention have found children in fair the development of airway inflammation and eventual
or poor health (38%) to be 3.5 times more alteration in the pulmonary physiology that is charac-
likely to have ever been diagnosed with asthma teristic of clinical asthma.
and almost 5 times more likely to still have The diagnosis of asthma usually is based on
asthma (33%) compared with children in excel- phenotypic (observable) symptoms. Central
lent or very good health (11% and 7%) (14). to the symptom patterns is the presence of airway
In addition, infants with sensitivity to food inflammation, which is variable both from person
allergens early in life are more likely to develop to person and also in individuals based on the qual-
asthma (15). One study also showed that ity of symptom control. The level of symptom
patients who wheezed before age 2 were 4 times control helps determine the amount of medical
more likely to develop asthma later in life (16). support needed and is classified by terms such as
• Urban living: Asthma in the United States intermittent versus persistent or acute versus chronic.
appears to be more frequent in ethnic minori- Acute symptoms of asthma usually arise from
ties and in children growing up in poor urban bronchospasm and require and respond to bron-
neighborhoods and is least common in rural chodilator therapy, whereas chronic asthma is
areas in combination with farm animal expo- thought to be caused by irreversible airway edema,
sure. There are several environmental and and does not respond to rescue therapies such as
lifestyle factors associated with urban living bronchodilator.
that are suspected to promote the development The most current research findings on the mecha-
of asthma, particularly in the first few years of nisms of asthma and findings from clinical trials
life, including close living quarters, less time have led to therapeutic approaches that allow most
spent outdoors, and vehicle exhaust (17). In people who have asthma to participate fully in
one study, asthma was consistently reported activities they choose. As we learn more about the
less frequently among only younger farm- pathophysiology, phenotypes, and genetics of
reared children, suggesting that exposures oc- asthma, treatments will become available to ensure
curring early in life have a significant effect in adequate asthma control for all patients and, ideally,
modifying the incidence or risk of asthma (18). to reverse and even prevent asthma processes. The
National statistics and differences in state re- challenge for respiratory therapists remains to help
porting requirements, however, make it difficult all patients with asthma, particularly those at high
to accurately quantify urban versus rural or risk, receive quality asthma care (2).
farm asthma rates. The role of air pollution in
the development of asthma remains controver- Pathophysiology
sial and may be related to allergic sensitization The airways are in continuous contact with the out-
(19). One epidemiological study showed that side world, which makes them susceptible to contact
heavy exercise (three or more team sports) out- with allergens as well as potentially harmful physi-
doors in communities with high concentrations cal, chemical, and biological agents. For patients
of ozone was associated with a higher risk of with asthma, this can start a chain reaction that will
asthma among school-aged children (20). cause airflow limitation and dyspnea (a subjective
• Socioeconomic status: Research has found that feeling of shortness of breath). Airflow limitation in
children in poor families are more likely to asthma is recurrent and caused by a variety of
have been diagnosed with asthma (17%) or to changes in the airway. These include airway edema,
still have asthma (12%) than children in fami- bronchoconstriction, airway hyperresponsiveness,
lies that were not poor (12% and 8%) (6). and airway remodeling (Fig. 13-1). Mucous plug-
ging is an additional factor that contributes to air-
Despite all these risk factors, there is not a clear
flow limitations.
picture of asthma or its cause in any age or population.
The prevalence of asthma across regional, national, • Airway edema: When asthma becomes more
and international populations also varies widely, persistent, airway edema develops as fluid be-
suggesting that both genetic and environmental expo- gins to accumulate in the interstitial spaces of
sures may influence the development of asthma. It is the airway, limiting localized air flow.
hypothesized that environmental factors such as infec- • Bronchoconstriction: The dominant physiologi-
tions and exposure to endotoxins may protect against cal event leading to clinical symptoms of
asthma or may facilitate its development, depending asthma is airway narrowing and a subsequent
2831_Ch13_307-354 13/03/14 3:32 PM Page 311
Airway Inflammation
Inflammation is a central part in the pathophysiol-
Edema ogy of asthma. Airway inflammation involves an
Mucus interaction of many cell types and multiple media-
tors with the airways that lead to bronchial inflam-
Normal bronchiole Asthmatic bronchiole mation and airflow limitation presenting clinically as
Figure 13-1 Model of Asthma coughing, wheezing, and shortness of breath. The
process by which this inflammation occurs and leads
to clinical asthma is still not well understood. Inflam-
interference with airflow. In acute exacerbations mation is a consistent part of all phenotypes of
of asthma, bronchial smooth muscle contraction asthma, although patients may have different triggers,
(bronchoconstriction) occurs quickly to narrow and it is suspected that different inflammatory cells
the airways in response to exposure to a variety are involved in different types of asthma (Fig.13-2).
of stimuli, including allergens or irritants. There are thought to be two possible mechanisms
• Airway hyperresponsiveness: Airway hyperre- causing airway inflammation during asthma: acute
sponsiveness, an exaggerated bronchoconstrictor and chronic. All asthma begins as an acute (or type I)
response to a wide variety of stimuli, is a major, response; at some point during the disease, some pa-
but not necessarily unique, feature of asthma. tients may experience chronic inflammation.
The degree to which airway hyperresponsive-
ness can be quantified by challenge tests, such Type I Hypersensitivity Response (Acute
as with methacholine, correlates with the clini- Inflammation)
cal severity of asthma. The mechanisms influ- The acute inflammatory cascade in asthma begins
encing airway hyperresponsiveness are multiple with the introduction of a trigger, known as a foreign
and include inflammation, dysfunctional antigen, into the airway. Foreign antigens are chem-
neuroregulation, and structural changes. ical or physical irritants that are capable of eliciting
• Airway remodeling: Chronic and severe asthma an immune response. In asthma, these antigens could
in children and adults is associated with thick- be any of the allergic or nonallergic triggers, such as
ening of the airway walls. As a consequence, pet dander, dust, pollution, cold air, or cigarette
airflow limitation may be only partially smoke. Antigens come into contact with the airway
reversible for some people with asthma—they and are captured by one of three cells:
may always have a certain amount of airway
• Macrophages: immune cells found in high
narrowing. Permanent structural changes can
numbers in the airway that engulf foreign
occur in the airway and are associated with a
antigens
progressive loss of lung function that is not
• Dendritic cells: located beneath the airway
prevented by or fully reversible by therapy. It is
epithelium, with sensory nerves projecting into
believed that this airway remodeling is caused
the epithelium to detect physical and chemical
by both the inflammation and repeated and
irritants
continuous incidences of bronchoconstriction
• Epithelial cells: cells that capture foreign anti-
(21, 22), with consequent permanent changes
gens and send out chemokines (chemical sig-
in the airway that increase airflow obstruction
nals) to white blood cells to stimulate an
and airway responsiveness and can cause a pa-
immune response
tient to be less responsive to therapy. The struc-
tural changes found in airway remodeling can These cells will present the antigens to T-cell lym-
include the following: phocytes found within the airway mucosa. T cells
• Thickening of the subbasement membrane are a type of white blood cell (WBC) responsible for
• Fibrosis of airway tissues the body’s immune response. T cells will multiply to
• Increase in airway smooth muscle tissue neutralize and/or eliminate the antigen. The T cells
• Blood vessel proliferation and dilation bind to another type of lymphocyte called a B cell,
• Excessive airway wall collagen deposition which will release a chemical signal called a cy-
• Mucous gland hyperplasia and hypersecretion tokine to change the B cell into a plasma cell. The
Regulation of the repair and remodeling process plasma cell releases immunoglobulin E (IgE), which
is not well established, but both the process of binds to mast cells in the airway to stimulate the
2831_Ch13_307-354 13/03/14 3:32 PM Page 312
patients and prevented in high-risk groups. It is the natural history of asthma is to offer treatment
hoped that this will slow or halt airway remodeling strategies that will prevent the progression of airway
and loss of lung function in groups of children who inflammation to airway remodeling and irreversible
are otherwise suffering from permanent loss of lung airway obstruction for children who are in a high-
function. Another important effect of understanding risk category.
2831_Ch13_307-354 13/03/14 3:32 PM Page 314
a 49% increase in the risk of needing acute their families to minimize the likelihood for exposure
asthma care each year, even after adjusting for to the triggers and the subsequent need for treatment.
other risk factors (50).
Nocturnal Asthma
Nonallergic Triggers
Currently, there is no thorough understanding of the
Other, nonallergic triggers within the home and causes of nocturnal asthma or the increase in asthma
other environments can exacerbate asthma symp- symptoms at night for some people. There have been
toms. These include tobacco smoke, vehicle emis- many suggested mechanisms for the cause of noctur-
sions, nitrogen dioxide, and particulate matter from nal asthma, but studies that have isolated each indi-
wood or gas stoves. Common seasonal viruses can vidual suspect have not resulted in any definitive
also exacerbate asthma. results to either pinpoint the cause or alleviate the
• Tobacco smoke: Environmental tobacco smoke symptoms. This leads experts to believe that it is the
has been linked to an increased risk of develop- interaction of several of these physiological and
ing asthma as well as increased severity and environmental mechanisms that contribute to noc-
frequency of exacerbations in children with turnal asthma symptoms.
asthma (51). Potential mechanisms are as follows: (59)
• Air pollutants: Exposure to traffic-related air
• Sleep state-induced increased airway parasym-
pollutants has been associated with respiratory
pathetic tone: This is a potential physiological
symptoms and asthma morbidity, but the effects
mechanism that occurs during sleep that may
of chronic air pollution exposures in susceptible
make bronchoconstriction more likely to occur
populations such as urban children are not well-
when triggered.
characterized (52). Data from studies from the
• Decreased lung volume and subsequent airway
last decade support the hypothesis that traffic-
smooth muscle unloading: Typically, bronchial
related air pollution increases the asthma symp-
reactivity is greater at lower lung volumes than
toms and the frequency of health service
at higher. Furthermore, when individuals refrain
contacts for asthma, but researchers are still
from sighs or deep inspiration, typically in-
evaluating the proximity to and amount of
creased airway reactivity rapidly ensues. In sleep,
vehicle emissions exposure required to see a
fewer deep breaths or sighs are initiated, which
significant increase in symptoms (52–55).
will lower lung volume. Theoretically, this can
• Nitrogen dioxide: The primary source for nitro-
result in unloading of airway smooth muscle,
gen dioxide within the home is a gas cooking
which can contribute to increased bronchocon-
appliance. A 2006 study of 728 homes with
striction and may be an important factor lead-
children diagnosed with asthma found that ex-
ing to nighttime exacerbation of asthma.
posure to indoor NO2 at levels well below the
• Circadian modulation of respiratory function: The
U.S. Environmental Protection Agency out-
mechanisms by which circadian rhythms (physio-
door standard (53 ppb) is associated with in-
logical phenomena that occur at approximately
creased respiratory symptoms if the children
24-hour increments, commonly known as the
lived in multifamily housing (56).
“biological clock”) influence pulmonary function
• Wood and gas stoves: Use of gas stoves and wood-
in asthma are unknown, although several possi-
burning appliances or fıreplaces have been associ-
bilities have been evaluated. Autonomic tone ex-
ated with increased wheezing in schoolchildren
hibits circadian variability, meaning that there
and increased asthma exacerbations (57).
may be times in the day that bronchial smooth
• Viral respiratory infections: In addition to aller-
muscle has more or less tone. Airway parasympa-
gen and air pollutants, the asthmatic airway is
thetic tone is also increased at night, but changes
particularly susceptible to respiratory virus in-
in state from wakefulness to sleep may be the
fection as a cause of 40% to 80% of asthma
most important factor modulating parasympa-
exacerbations both in children and adults (58).
thetic flow to the airways rather than circadian
Of particular significance is the finding in
rhythms. Circadian variation in the portions of
asthma that the common cold viruses (e.g., rhi-
the nervous system that encourage bronchodila-
novirus), which usually causes only upper respi-
tion may also contribute to a nighttime decrease
ratory tract symptoms, causes exacerbations,
in airway function. Airway leukocyte, neutrophil,
especially in the spring, fall, and winter months.
and eosinophil counts have been shown to be
In summary, a variety of triggers in the home can greater in patients with nocturnal asthma during
worsen asthma symptoms. Understanding all the po- the early morning hours compared with after-
tential environmental and physiological components noon levels, suggesting that the airways may be
that contribute to exacerbation will help children and more inflamed overnight than during the day.
2831_Ch13_307-354 13/03/14 3:32 PM Page 317
be clearly defined for each person to ensure that safe asthma. The medical history can help identify the
decisions are made about asthma management. symptoms likely to be due to asthma and support the
likelihood of asthma. See Box 13-4 for an example
Diagnosis of Asthma patient history form. The history should include
The first step in controlling asthma is to estab- items regarding the following:
lish a definitive diagnosis. Clinicians should deter-
• Symptoms
mine that episodic symptoms of airflow obstruction
• Pattern of symptoms
or airway hyperresponsiveness are present, airflow
• Precipitating and/or aggravating factors
obstruction is at least partially reversible, and alter-
• Development of disease and treatment
native diagnoses are excluded.
• Family history
Asthma should be suspected when any of the
• Social history
following have occurred (Box 13-3):
• History of exacerbations
In the past 12 months • Impact of asthma on patient and family
• Assessment of patient’s and family’s percep-
• A sudden severe episode or recurrent episodes
tions of asthma (2)
of coughing, wheezing, chest tightness, or
shortness of breath Physical Examination
• Colds that seem to “go to the chest” or take
more than 10 days to resolve The upper respiratory tract, chest, and skin are
• Coughing, wheezing, or shortness of breath the focus of the physical examination for asthma.
• During a particular season or time of the Physical findings that increase the probability
year of the disease are listed below. The absence of
• In certain places or when exposed to certain these findings does not rule out asthma because
things (e.g., animals, tobacco smoke, perfumes) the disease is by definition variable, and signs
• Using medications that improve breathing of airflow obstruction are often absent between
• Symptom relief when the medications are used attacks.
6
FEF 50%
umes with normal flow measurements (i.e., a reduced 5
FVC with a normal or FEV1/FVC ratio) suggests a re- 4
3 FEF 25%
strictive disease. The severity of abnormality of PFT 1 sec
Flow (L/sec)
2
measurements is evaluated by comparing a patient’s 1 FEV1
results with reference values based on age, height, sex, TLC 0 RV
and race (65). Up until 2008, however, normal values ⫺1 75 50 25
⫺2
had not been formally assessed for children less than ⫺3
Inspiration
A positive test for BPT would consist of a reduc- Fractional Exhaled Nitric Oxide
tion in FEV1 greater than 20%, which indicates the Fractional exhaled nitric oxide (FeNO) is the most
patient as having airway hyperresponsiveness. widely used exhaled biomarker of airway inflamma-
Likewise, an increase in FEV1 of at least 20% is tion in asthma. Levels of nitric oxide in exhaled
considered a positive response to bronchodilator breath can be measured relatively quickly in an
therapy (72). outpatient clinic, although the gas analyzers required
are expensive. FeNO is often increased in patients
Allergy Testing
with atopic asthma and severe asthma and is corre-
Environmental allergens are a major trigger of lated with airway eosinophilia (74). It has been
asthma, but not all asthmatics have allergies. It can suggested that FeNO can be most useful to predict
be challenging to determine when allergy skin testing the likelihood of response to inhaled steroid therapy.
will be useful to help with the diagnosis of asthma. The suggested values of FeNO vary. Low FeNO
The NAEPP currently recommends that patients be levels (less than 25 parts per billion) indicate that the
tested only for sensitivity to the allergens to which patient is unlikely suffering from eosinophilic asthma
they may be exposed, followed by an assessment of and is less likely to respond to steroids. A high FeNO
the clinical relevance of the sensitivity, and that test- level (greater than 50 parts per billion) strongly sug-
ing be limited to patients who have persistent asthma gests airway eosinophilia and steroid responsiveness
and are exposed to indoor allergens. Allergy tests are (75). The level of FeNO can also be useful to assess
also an essential part of educating patients about the whether the present dose of inhaled corticosteroid is
role allergens play in their disease. adequate to control airway inflammation. A 2009
In children, the clinical symptoms for allergic and Cochrane Review of the research related to FeNO’s
nonallergic asthma are the same. One study attempting use for tailoring treatment strategies such as dosage
to find differences between the two failed to identify of steroid therapy did not recommend FeNO for this
any combination of features that could reliably distin- purpose, but did agree regarding its usefulness to
guish allergic from nonallergic asthma in children (73). monitor eosinophilic asthma (76).
Two-thirds of the children in the study diagnosed with
asthma had at least one positive skin test. Thus, the Exhaled Breath Condensate
recommendation from this study was that all children Exhaled breath condenses when it comes into contact
with asthma should undergo allergy testing to identify with a cooled collector, allowing the collection of res-
potential allergic triggers and to prevent instituting piratory particles, droplets, and water vapor. The pH
unnecessary environmental control measures. of exhaled breath condensate has been shown to relate
The skin test method of allergen evaluation is well to airway inflammation. Low exhaled breath conden-
known and consists of approximately 50 to 200 tiny sate pH is a biomarker that indicates poorly controlled
scratches, pricks, or needle sticks made on the upper eosinophilic asthma in a manner similar to high FeNO
back or arm with small amounts of suspected aller- (77). There is currently no standard type of condenser
gens. After an appropriate time period (10 to 30 min- used to collect exhaled breath condensate. The differ-
utes), the skin is observed for any reaction. With the ing surface properties of each condenser type will
discovery of the IgE antibody, in vitro testing has be- cause significant variation in the nature of the particles
come possible. Using this method, a blood sample is collected. Variations can also be caused by exercise and
mixed with different allergens and observed for a environmental conditions (78). This makes it difficult
chemical reaction. The laboratory’s equipment and to compare condensate values between sites or studies
computers analyze the reaction and measure the until standards are better defined.
amount of IgE for each allergen. Results are grouped
into classes from 0 (negative) to 6 (high positive). Sputum Eosinophils
Sputum samples can offer many biomarkers. The
Biomarkers of Inflammation percentage of eosinophils in sputum directly meas-
Biomarkers are biochemical, genetic, or molecular ures airway inflammation and is one method of
indicators that can be used to screen for diseases. objectively monitoring asthma. Patients with asthma
They are already in use to aid in the diagnosis of car- have significantly higher percentages of sputum
diovascular disease and cancer. Biomarkers of eosinophils than do patients without asthma. This
inflammation can be obtained from sputum, blood, biomarker has been used specifically for tailoring
urine, and exhaled air. Their use as aids to the diag- asthma interventions and has been found to be
nosis and assessment of asthma is currently being beneficial in reducing the frequency of asthma exac-
evaluated in clinical research trials. Because asthma erbations in adults with frequent exacerbations and
is a heterogeneous disease, it will require multiple severe asthma, although its effectiveness has not been
biomarkers for accurate diagnosis. evaluated for children (79).
2831_Ch13_307-354 13/03/14 3:32 PM Page 323
Upper Airway Diseases Allergic rhinitis and sinusitis • COPD (e.g., chronic bronchitis
Large Airway Obstructions • Foreign body in trachea or bronchus or emphysema)
• Vocal cord dysfunction • Congestive heart failure
• Vascular rings or laryngeal webs • Pulmonary embolism
• Laryngotracheomalacia, tracheal • Mechanical obstruction of the
stenosis, or bronchostenosis airways (e.g., benign and malig-
• Enlarged lymph nodes or tumor nant tumors)
• Pulmonary infiltration with
Small Airway Obstructions • Viral bronchiolitis or obliterative bron- eosinophilia
chiolitis • Cough secondary to drugs (e.g.,
• Cystic fibrosis angiotensin-converting enzyme
• Bronchopulmonary dysplasia inhibitors)
• Heart disease • Vocal cord dysfunction
Other • Recurrent cough not due to asthma
• Aspiration from swallowing mechanism
dysfunction or gastroesophageal reflux
2831_Ch13_307-354 13/03/14 3:32 PM Page 324
Classifying the Severity of Asthma The specific measures used for classifying severity
Once the diagnosis of asthma has been established, include the following:
information obtained from the diagnostic evalua- • Symptoms
tion, and additional information, if necessary, • Use of short-acting beta agonists for quick
should be used to characterize the patient’s asthma relief
in order to guide decisions for therapy. The NAEPP • Exacerbations
recommends that clinicians classify asthma severity • Pulmonary function
by using the domains of current impairment and
future risk. Asthma severity is the intrinsic intensity The distinction between impairment and risk em-
of disease. Initial assessment of patients who have phasizes the need to consider separately asthma’s
confirmed asthma begins with a severity classifica- effects on quality of life and functional capacity on
tion because the selection of type, amount, and an ongoing basis and the risks asthma presents for
scheduling of therapy should correspond to the level adverse events in the future, such as exacerbations
of asthma severity. This initial assessment of asthma and progressive loss of pulmonary function.
severity is made immediately after diagnosis or when Assessing Impairment
the patient is first encountered, before he or she is
Classifying asthma severity requires assessing the
taking some form of long-term control medication.
following components of current impairment:
Assessment is made on the basis of current spirom-
etry results and the patient’s recall of symptoms over 1. Symptoms
the previous 2 to 4 weeks. If the assessment is made • Nighttime awakenings
during a visit in which the patient is treated for an • Need for short-acting beta agonist for quick
acute exacerbation, then asking the patient to recall relief of symptoms
symptoms in the period before the onset of the • Work/school days missed
current exacerbation will suffice until a follow-up • Ability to engage in normal daily activities
visit can be made. For individual patient manage- or in desired activities
ment, the goal is to assess asthma severity prior to • Quality-of-life assessments
initiating therapy and then to assess control for mon- 2. Lung function, measured by spirometry
itoring and adjusting therapy. The severity classifica- • FEV1
tion of asthma is shown in Table 13-2 and uses the • FVC (or FEV6)
two domains of current impairment and future risk. • FEV1/FVC
There is some question about the usefulness of such as spirometry or peak expiratory flow. These
serial PFT results in children. Making treatment objective measures more reliably indicate the severity
decisions for children should be based on frequency of an exacerbation than does the severity of symp-
and severity of past exacerbations and symptoms, toms. Milder exacerbations may be managed outside
with pulmonary function measures used as an addi- the health-care system, whereas more serious exac-
tional guide. erbations may require an urgent office visit, a trip to
an emergency department, or a hospital admission.
Assessing Risk The most severe exacerbations require admission to
A closely related and second dimension of severity the ICU for optimal monitoring and treatment. Clin-
is the concept of risk of adverse events, including ical manifestations of an acute exacerbation are dif-
exacerbations and risk of death. Assessment of the ferent depending on the age of the patient.
risk of future adverse events requires careful medical For infants, assessment relies heavily on physical
history, observation, and clinician judgment. Docu- examination and includes the following findings:
mentation of warning signs and adverse events will • Use of accessory muscles
be necessary when a patient is felt to be at increased • Inspiratory and expiratory wheezing
risk. Patients who are deemed at increased risk of • Paradoxical breathing
adverse outcomes need close monitoring and fre- • Cyanosis
quent assessment by their clinicians. • SpO2 less than 90%
Although the classification of severity focuses on • Respiratory rate greater than 60 breaths/min
the frequency of exacerbations, it is important to • Poor feeding
note that the severity of disease does not necessarily
correlate with the intensity of exacerbations, which It can also be challenging with preschool-aged
can vary from mild to very severe and life-threaten- children to assess clinical signs and symptoms of
ing. Determination of whether the level of severity exacerbation accurately and make a decision about
is mild, moderate, or severe will depend on consid- treatment and hospital admission. More than a
eration of both the frequency and the intensity of dozen clinical scores assessing acute asthma have
the exacerbations. Predictors reported to be associ- been published, but few have been validated. The
ated with increased risk of exacerbations or death Preschool Respiratory Assessment Measure, for
include the following: example, is one that has been validated for children
ages 3 to 6 years, although it may not be used exclu-
• Severe airflow obstruction, as detected by sively (80). Therapists should be aware of the tools
spirometry used in their institution and be trained in their use.
• Persistent severe airflow obstruction Markers of severe asthma exacerbation for all
• Two or more ED visits or hospitalizations for patients include the following:
asthma in the past year
• Any history of intubation or intensive care • Difficulty talking in full sentences
unit (ICU) admission, especially if in the past • SpO2 90% to 92%
5 years • PaO2 less than 60 mm Hg
• A patient reporting that he or she feels in dan- • Partial pressure of carbon dioxide (PaCO2)
ger or frightened by his or her asthma greater than 42 to 45 mm Hg
• Certain demographic or patient characteristics • Use of accessory muscles
such as female, nonwhite • Pulsus paradoxus (a greater than 15 mm Hg
• Nonuse of inhaled corticosteroid therapy drop in systolic blood pressure during
• Current smoking inspiration)
• Psychosocial factors such as depression, • Quiet chest (diminished breath sounds, no
increased stress, socioeconomic factors wheezing)
• Attitudes and beliefs about taking medications • Patient unable to lie supine
(2) • Cyanosis
• Sweating
Asthma Exacerbations • Confusion
• Decreased level of consciousness
Exacerbations of asthma are acute or subacute • Hypotension or bradycardia (81)
episodes of progressively worsening shortness of
breath, cough, wheezing, and/or chest tightness. Arterial blood gas (ABG) presentations in
Exacerbations are characterized by decreases in acute exacerbation can vary. In patients who
expiratory airflow that can be documented and are tachypneic but still effectively ventilating, the
quantified by simple measurement of lung function ABG results will show respiratory alkalosis with
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Table 13-3 Severity of Asthma Exacerbations in the Urgent or Emergency Care Setting (2)
Signs and Symptoms Initial PEF (or FEV1) Clinical Course
Mild Dyspnea only with PEF ≥70% predicted Usually cared for at home
activity (assess tachyp- or personal best Prompt relief with inhaled
nea in young children) SABA
Possible short course of oral
systemic corticosteroids
Moderate Dyspnea interferes with PEF 40%–69% pre- Usually requires office or ED
or limits usual activity dicted or personal visit
best Relief from frequent inhaled
SABA
Oral systemic corticosteroids
Some symptoms last for
1–2 days after treatment is
begun
Severe Dyspnea at rest; inter- PEF <40% predicted Usually requires ED visit and
feres with conversation or personal best likely hospitalization
Partial relief from frequent in-
haled SABA
Oral systemic corticosteroids
Some symptoms last for
>3 days after treatment is
begun
Adjunctive therapies are
helpful
Status Asthmaticus Too dyspneic to speak; PEF <25% predicted Requires ED/hospitalization;
Life-Threatening perspiring or personal best possible ICU
Minimal or no relief from
frequent inhaled SABA
Intravenous corticosteroids
Adjunctive therapies are
helpful
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Status asthmaticus refers to severe, persistent, and Box 13-5 Goals of Long-Term Asthma
intractable asthma that does not respond to initial Therapy (2)
short-acting beta-agonist therapy. Typically, a patient
will present following exposure to a potent allergen 1. Reduce impairment
or irritant, a few days after the onset of a viral respi- • Prevent chronic and troublesome symptoms
ratory illness, or after exercise in a cold environment. • Require infrequent use (2 or fewer days a
A patient may also have underused or have been week) of inhaled SABA for quick relief of
underprescribed anti-inflammatory therapy. Patients symptoms, not including prevention of
report chest tightness, rapidly progressive shortness exercise-induced bronchospasm
of breath, dry cough, and wheezing. Status asthmati- • Maintain near-normal pulmonary function
cus is a medical emergency that requires prompt • Maintain normal activity levels, including
assessment and treatment from the health-care team. exercise, other physical activity, and atten-
dance at work or school
■ ■ Based on Derrick’s symptoms, you and the • Meet patients’ and families’ expectations of
pulmonologist agree that he has mild persistent and satisfaction with asthma care
asthma. Although he has been sent home with a 2. Reduce risk
short-acting beta agonist in the past, you both agree • Prevent recurrent exacerbations of asthma
that he should have some form of maintenance ther- and minimize the need for emergency depart-
apy to minimize the inflammation present in his ment visits or hospitalizations
airways and to improve his nighttime and winter • Prevent progressive loss of lung function or
symptoms. prevent reduced lung growth (in children)
• Provide optimal pharmacotherapy with
minimal or no adverse effects
he or she will perform a PEF twice daily. A PEF self-management of school-aged children (86). Even
measurement is taken by having the patient stand, when not completed every day, periodic daily PEF
take a deep breath to fill the lungs completely, then monitoring may be useful when changing treatment
blow out as hard and as fast as possible in one single strategies or helping teach patients a better under-
exhalation. When this is performed with a mouth- standing of airflow obstruction.
piece PFM, the indicator will tell the maximum, or
peak, expiratory flow generated. A personal best is Pharmacological Therapy
documented as the “goal” PEF, and future measure- Medications for asthma are categorized into two
ments will be read as a percentage of this ideal num- general classes: (1) long-term control medications
ber. This is then used to assess the severity of an used to achieve and maintain control of persistent
exacerbation and used to help guide decisions on asthma and (2) quick-relief medications used to
when to seek medical assistance. Studies have found treat acute symptoms and exacerbations. The main-
that children had low compliance with twice daily stay for asthma is an anti-inflammatory for chronic
PEF (84), the values were less accurate when management and a short-acting beta agonist for
compared with PFT measurements such as FEV1 acute exacerbations. Table 13-4 presents the NAEPP
(85), and the values were ineffective in helping with stepwise approach to asthma management based on
compelling evidence to recommend one ICS over whether cromones or ICS are superior in managing
others for specific populations (90, 91). There is also persistent asthma, there is still a role for cromones,
no consensus on whether to start with high doses of and they are recommended by the NAEPP as an
ICS and taper the dose down or to start with low alternative medication for treatment of mild persistent
doses and increase until the patient is asymptomatic. asthma and as preventive treatment prior to exercise
Current trends suggest starting with a moderate dose or unavoidable exposure to known allergens.
and decreasing the dosage as able (92). Some corti- XANTHINES
costeroids are available for delivery as both an in- Xanthines, such as theophylline, are classified as bron-
haler and SVN. There is no evidence that one chodilators, although they have much less potency
delivery method is superior (93), though DPI than do beta-2 agonists such as albuterol. They are
requires coordination of breathing and posture that stimulants, generally stimulating the central nervous
may not be possible in young children. system and cardiac muscles, but they may also simu-
CROMONES late the respiratory drive or strengthen the diaphragm
Cromones such as cromolyn sodium and nedocromil muscles. The exact mode of action is unclear. Sus-
stabilize mast cells and interfere with chloride channel tained-release theophylline is a mild to moderate
function, preventing the release of mediators and bronchodilator that can be used as an alternative, not
minimizing airway inflammation. Nedocromil also preferred, adjunctive therapy with ICS for children
blocks the activity of eosinophils, airway epithelial greater than 5 years old. Theophylline may also have
cells, and sensory neurons, potentially causing a more mild anti-inflammatory effects. Excessive amounts of
potent protective effect. Cromolyn sodium is available theophylline have been shown to cause headaches,
in nebulized and MDI forms, and nedocromil is avail- nausea, cardiac arrhythmias, and seizures, thus mon-
able as an MDI. Recommended dosage is two puffs itoring of serum theophylline concentration is essen-
four times a day or one ampule for nebulization. tial in order to maintain within a therapeutic range
Studies have shown that although cromones exhibit of 5 to 15 mcg/mL during asthma management (97).
fewer side effects, they are not as effective at prevent- Dosages and dosing schedules should be titrated
ing inflammation or providing symptom-free days as based on serum theophylline levels to maintain the
ICS (94–96). Although research has not established correct therapeutic range.
2831_Ch13_307-354 13/03/14 3:32 PM Page 334
Studies have shown that other medications are risk of severe asthma attacks after future exposure
more effective at managing lung function than theo- to the allergen (100). It is possibly as effective as ICS.
phylline. Long-acting beta agonists, particularly sal- Another form of immunotherapy is known as anti-
meterol, are more effective than theophylline in IgE therapy. Omalizumab is a monoclonal antibody
improving morning and evening PEF, but are not sig- that prevents binding of IgE to mast cells, thereby re-
nificantly different in their effect on FEV1 (98). Fewer ducing the number of mediators released in allergic
adverse events occurred in participants using long- reaction and decreasing airway inflammation. It can
acting beta agonists as compared to theophylline. be used as adjunctive therapy for patients 12 years of
When reviewing the evidence for children, there is not age and older who have allergies and severe persistent
enough research data to make firm conclusions about asthma. Like traditional immunotherapy, anti-IgE
the effectiveness of xanthines as add-on preventive therapy involves a subcutaneous injection, and clini-
treatment to ICS, and there are no published pedi- cians who administer omalizumab should be pre-
atric studies comparing xanthines with alternatives in pared and equipped to identify and treat anaphylaxis
this role (99). The data suggest that xanthines are only that may occur. A review of research trials found that
suitable as first-line preventive asthma therapy in chil- anti-IgE therapy led to a reduction, and in some
dren when ICS are not available, but they may have a cases, withdrawal, of regular inhaled steroid use and
role as add-on therapy in more severe asthma not a reduction in asthma exacerbations. The side effects
controlled by ICS. were few and mild to moderate in the short term, but
ANTILEUKOTRIENE longer-term evaluation is needed. Patient and physi-
Antileukotrienes, also known as leukotriene modi- cian assessments of the effectiveness of therapy were
fiers or leukotriene receptor antagonists (LTRA), act positive. It may be useful in cases of uncontrolled
by preventing leukotrienes from causing airway moderate to severe asthma (101).
inflammation in asthma. They are recommended for ANTIHISTAMINES
the prophylactic and chronic treatment of asthma For children with allergic asthma, antihistamines
patients 12 years and older. Antileukotrienes work may assist in managing asthma symptoms. Ketotifen
by inhibiting enzymes that act in the formation of is an oral medication that may be used for mainte-
leukotrienes, thus stopping the inflammatory path- nance treatment of asthma. It is an oral antihista-
way and preventing airway inflammation. There are mine whose mechanism of action is not fully
three different antileukotrienes on the market cur- understood, but it may inhibit the release of inflam-
rently, which are available as oral pills or granules in matory mediators and inhibit bronchospasm by
varying strengths and dosages: reducing calcium uptake in mast cells and in smooth
muscle. As an oral preparation, ketotifen might be
• Zileuton
useful in managing children with asthma, especially
• Zafirlukast
in the preschool age, where independent inhaled
• Montelukast
therapy can be difficult to perform. Randomized
Zileuton is available only for patients 12 years and controlled trials indicate that ketotifen alone or
older, whereas zafirlukast is approved for children in combination with other asthma interventions
5 years and older and montelukast has preparations improves control of asthma and wheezing in children
approved for infants and children 6 months and with mild and moderate asthma (102).
older. The NAEPP asthma guidelines clearly state LONG-ACTING BETA AGONISTS
that corticosteroids are the most effective anti-inflam- Long-acting beta agonists (LABAs) are used in com-
matory drug; antileukotrienes are recommended as a bination with ICS for long-term control and preven-
secondary and adjunct drug after ICS and long- tion of symptoms in moderate or severe persistent
acting beta agonists have been tried. asthma. They work by reversing the narrowing of the
IMMUNOTHERAPY airways that occurs during an asthma attack. Avail-
Allergen-specific immunotherapy involves having able alone as MDI or in combination with different
subcutaneous injections of increasing amounts of a ICS, they are known to improve lung function, symp-
known allergen under the skin. It is also known toms, and quality of life, and to reduce the number of
as allergy hyposensitization or desensitization. The asthma attacks (103, 104). LABAs have been shown
injections are formulated based on an individual’s to lead to fewer asthma symptoms during the day and
allergic sensitivities and provided at a physician’s of- the night, less bronchodilator medication required to
fice on a regular basis (e.g., weekly). Side effects of relieve symptoms, better lung function measurements,
the therapy include a lump at the injection site, rash, and better quality-of-life measurements compared to
wheezing, breathlessness, and very rarely, a fatal short-acting beta agonists (105). They have also been
allergic reaction known as anaphylaxis. The review shown to be superior to antileukotrienes in reducing
of trials found that immunotherapy can reduce oral steroid-treated exacerbations in adults, but this
asthma symptoms, the need for medications, and the conclusion is not yet evidenced in children (106).
2831_Ch13_307-354 13/03/14 3:32 PM Page 335
■ ■ The pulmonologist tells Derrick and his grand- designed very differently; thus, it is not possible to
mother that he probably has asthma. Although there compare their efficacy with traditional daily control
are many more tests that would help them better regimens recommended by the NAEPP (Evidence in
understand what triggers his asthma, they are Practice 13-1).
expensive and time consuming and may not offer
additional useful information. Though you and the
pulmonologist are not sure what causes Derrick’s ● Evidence in Practice 13-1
worsening symptoms, the pulmonologist recom-
mends that Derrick no longer bring furry animals Herbal Therapy for Asthma (116)
inside and avoid having feather pillows and other A 2008 Cochrane Database Review sought to identify
potential allergic triggers in the house. He provides a which herbal interventions may improve asthma
list of helpful recommendations for changing the symptoms. The review looked at 21 different herbal
home environment. Additionally, he prescribes Der- preparations, many of which are commonly used in
rick an ICS—Pulmicort, 200 mcg—to be used one China where they are considered “conventional” treat-
actuation, twice a day. The clinic has a free 1-month ment. Some of the more promising results are
supply of Pulmicort that you will send home with him described here.
to use until they can fill the prescription. He is also
prescribed an MDI of albuterol and spacer, which • Boswellia extract has been used as an anti-
you demonstrate how to use. You also give him a inflammatory herbal product. Studies showed an
PFM to monitor his symptoms over the next few increase in FEV1, peak expiratory flow rate (PEFR),
weeks and encourage him to find his personal best and FVC in at least one set of subjects reviewed.
number with which he can compare his breathing Side effects included nausea, epigastric pain, and
when he starts to feel short of breath. He is also sent hyperacidity for some.
home with an asthma action plan that describes • Mai-Men-Dong-Tang, also known as Ophiopogon
when to take all of his medications and which symp- Combination, is a natural Chinese medication
toms should prompt immediate help. In addition, you used for both stomach and lung dysfunctions to
provide copies of the action plan for the school moisten dryness in the digestive and pulmonary
nurse and his teacher. tracts. The review found an increase of FEV1 in a
The pulmonologist asks Derrick to come back to statistically significant number of subjects.
the clinic in 2 months so that he can follow up on his • Propolis is a resin-like material from the buds of
symptom control and see how his symptoms were poplar and cone-bearing trees. It is used for its
for the remainder of the winter. anti-inflammatory properties. The review showed
positive effects in FEV1, PEFR, and FEF25-75, as
well as a reduction in nocturnal attacks.
• Also known as eucalyptol, 1.8-cineol, is the domi-
nant portion of eucalyptus oil. Its use with patients
Nonpharmacological Therapy with asthma showed no differences in PFT results,
but did allow for a reduction in oral steroid use and
Patients who suffer from asthma frequently search a reduction in dyspnea score.
for holistic ways to manage their daily symptoms of • Pycnogenol is extracted from a tree called the
asthma and minimize the risk of exacerbation. To Pinus pinaster, but can also be extracted from
date, there is little evidence supporting or refuting peanut or grape seed and witch hazel bark. It has
the effectiveness of many of these techniques. been used for allergies, circulatory problems, high
Although clinicians may not recommend any of blood pressure, varicose veins, and childhood
these complementary therapies, RTs should be aware asthma. In children, it has been shown to increase
of all therapies that patients may be using to control PEFR, reduce symptom scores, and significantly
their asthma. Examples of nonpharmacological decrease albuterol use.
therapies include herbal therapies, caffeine, dietary • Tylophora indica comes from the leaves and roots
changes and vitamin supplementation, acupuncture, of a climbing plant. It has been used in India for
manual therapy, breathing exercises, and physical more than a century to treat bronchial asthma, but
exercise. has also been suggested for diarrhea and hay fever.
Herbal Therapies In medical studies, patients have experienced an
increase in PEFR and reductions in symptom
Herbal interventions are one complementary therapy scores and the use of reliever medications such as
sought by patients whose asthma causes a decrease albuterol. Side effects include loss of salt taste (for
in actual or perceived quality of life. Several studies those who ingest by chewing on Tylophora leaves),
have shown some promise for different herbal reme- sore mouth, nausea, and vomiting.
dies, but the research for such remedies is usually
2831_Ch13_307-354 13/03/14 3:32 PM Page 337
have suggested that this is achieved (125). It is also a Any time that asthma is poorly controlled, an in-
relatively risk-free and inexpensive therapy, so it would crease in the step approach is warranted. Consultation
be a very desirable option for many patients with with an asthma specialist should be initiated once step
asthma. However, there is no consensus as yet on 3 care or higher is needed for children younger than
which breathing technique is most effective. 4 years and should be considered for any patient age
5 and older. Any patient requiring step 4 care or
Physical Exercise higher should be managed by an asthma specialist.
Physical exercise and training is recommended for For children 0 to 4 years old: If a clear and benefi-
all people who are physically capable, and it has cial response to the prescribed asthma treat-
been questionable whether exercise is possible for ment is not obvious within 4 to 6 weeks and the
patients with asthma. There has been no evidence patient’s and family’s medication technique and
of negative effects of physical training on lung func- adherence are satisfactory, treatment should be
tion and wheeze in patients with asthma (126). stopped. Alternative therapies or alternative
It can improve cardiopulmonary fitness and improve diagnoses should be considered. Once a clear
quality of life, but it does not seem to improve and beneficial response is sustained for at least
pulmonary function tests. 3 months, consider a step down to evaluate the
need for continued daily long-term control ther-
Assessing Asthma Control apy. Children in this age group have high rates
Once an asthma action plan has been developed and of spontaneous remission of symptoms.
a patient is sent home with his or her long-term ther- For patients 5 years and older: Declines in lung
apy, part of regular asthma management includes function or repeated periods of worsening
regular assessment of asthma control. Evaluation asthma impairment may indicate a progressive
should be done 2 to 6 weeks after any initiation worsening of the underlying severity of
of or change in an asthma plan. The step system asthma. Although there is no indication that
(see Table 13-4) allows clinicians to quickly adjust treatment alters the progression of the under-
pharmacological therapies up or down, depending lying disease in children, adjustments in treat-
on a patient’s level of control. Signs of poorly con- ment may be necessary to maintain asthma
trolled asthma include the following: control. Once asthma control is achieved,
monitoring and follow-up are essential be-
• Symptoms more than 2 days per week
cause asthma often varies over time. A step up
• Symptoms multiple times per day on 2 or more
in therapy may be needed at any time that
days per week
asthma is poorly controlled, or a step down
• Nighttime awakenings more than once a month
may be possible to identify the minimum med-
(0 to 4 years old), or twice a month or more
ication necessary to maintain control.
(5 years old and older)
• Some limitation with normal activity There is also the possibility of identifying seasonal
• Use of SABAs for symptom control more than patterns of asthma. One study found that poorly con-
2 days per week trolled asthma was present in one-third of children in
• FEV1 60% to 80% the summer, compared with close to half the asthma
• FEV1/FVC 75% to 80% population during spring, autumn, and winter (127).
• Exacerbations more than two times per year
requiring oral systemic corticosteroids Acute Exacerbations
An asthma exacerbation is an acute or subacute
Signs of very poorly controlled asthma include the
episode of progressively worsening shortness of
following:
breath, coughing, wheezing, and/or chest tightness. It
• Symptoms throughout the day is characterized by decreases in expiratory flow that
• Weekly nighttime awakenings (0 to 4 years old) can be quantified through simple measurements such
or more than 2 times per week (5 years and as PEF. Generally, milder exacerbations can be man-
older) aged at home using a quick-relief medication (usually
• Extremely limited activity levels a SABA), whereas more serious exacerbations require
• Use of SABAs for symptom control several an unscheduled visit to a doctor’s office, urgent care
times per day facility, ED, or a hospital admission. The most severe
• FEV1 less than 60% exacerbations, frequently referred to as status asth-
• FEV1/FVC less than 75% maticus, are those that do not respond to attempts at
• Exacerbations more than 2 (ages 5 years and bronchodilation with SABAs. They require admis-
up) to 3 (0 to 4 years) times per year requiring sion to an ICU for continuous monitoring and ad-
oral systemic corticosteroids vanced treatment.
2831_Ch13_307-354 13/03/14 3:32 PM Page 339
Decreased tidal volume or severe airway obstruc- an ED significantly reduces the need for hospital
tion in status asthmaticus may prevent effective admission in patients with acute asthma (141).
aerosolized bronchodilator delivery; thus, intravenous Prednisone, methylprednisolone, or prednisolone
delivery may be necessary. Terbutaline is the current are the systemic corticosteroids of choice for treat-
intravenous beta agonist of choice in the United ing asthma, and are administered in dosages of 1 to
States, whereas other countries also use albuterol. 2 mg/kg (maximum 60 mg/day), divided into two
Although most adverse effects of beta agonists are doses, delivered until PEF reaches 70% of predicted
cardiovascular in nature, neither albuterol or terbu- or personal best (2).
taline have been known to cause clinically significant ANTICHOLINERGICS
toxicity when used intravenously for pediatric status Anticholinergics have a much slower onset of action
asthmaticus (136). Oral delivery of albuterol is not (60 to 90 minutes to peak) and produce less bron-
an effective way to treat severe, acute asthma (129). chodilation at peak effect compared with SABAs.
A 2011 Cochrane Review of trials did not find The rationale for implementation of a combination
enough evidence to show that inhaled beta-2 agonists of SABAs and anticholinergic agents in patients with
work well for patients once they are intubated and severe asthmatic exacerbations is based on targeting
mechanically ventilated; thus, the current effect is not different sites of action (i.e., proximal vs. distal air-
established (137). Although more research is needed, ways) and different pathophysiological mechanisms
SABA therapy is typically continued for patients of airway smooth muscle relaxation (135). Iprat-
even after intubation. ropium bromide is the anticholinergic agent of
CORTICOSTEROIDS choice to administer to patients with asthma in the
Despite extensive clinical experience with corti- emergency setting because of its selectivity for mus-
costeroids, there remains considerable uncertainty as carinic airway smooth muscle receptors through
to the onset of action, dose-response characteristics, which bronchodilation is mediated and its lack of
duration of treatment, optimal route of administra- systemic anticholinergic adverse effects.
tion, and patient populations likely to require or A single dose of an anticholinergic agent is not
respond best to them during the treatment of acute effective for the treatment of mild and moderate
severe asthma (138). The treatment of acute severe exacerbations and is insufficient for the treatment of
asthma with corticosteroids within 1 hour of presen- severe exacerbations. Adding multiple doses of anti-
tation to the emergency department has been found cholinergics to beta-2 agonists appears safe, im-
to lower hospitalization rates and improve pulmonary proves lung function, and helps prevent hospital
function (139). The benefit of systemic corticosteroids admission in some patients. The available evidence
appears greatest in patients with more severe asthma, only supports their use in school-aged children with
and those not currently receiving steroids (140). Their severe asthma exacerbation, not for mild or moder-
onset of action may be seen in as little as 2 hours when ate exacerbations (142).
monitoring PEF, but improvement in FEV1 may be MAGNESIUM
delayed by as much as 6 hours (135). This is why cor- Magnesium is an ion found in abundance in the
ticosteroids should be given as quickly as possible, human body and, when given intravenously, has been
within 1 hour of presentation to the emergency shown to have beneficial effects on smooth muscle
department (2), and aggressive bronchodilator treat- relaxation and inflammation (143). The use of mag-
ment must continue until corticosteroids take effect. nesium sulfate in status asthmaticus has gained sup-
A clear dose response is seen at dosages greater port recently, appearing to be of some benefit in the
than 40 mg/day of methylprednisolone or the equiv- subpopulation of patients with severe airflow limita-
alent. Oral and intravenous corticosteroids have tion, a relative failure to respond to inhaled bron-
similar efficacy in the treatment of acute asthma in chodilators, and a high risk of hospital admission
adults, and children appear to respond well to oral (144). The addition of intravenous magnesium sulfate
dosing (139). Systemic corticosteroids produce some to the repetitive administration of inhaled SABAs
improvements for children admitted to the hospital and systemic corticosteroid treatment among individ-
with acute asthma. The benefits may include earlier uals with severe exacerbations is shown to reduce hos-
discharge and fewer relapses, and continuing a pitalizations and improve pulmonary function (135).
course of oral corticosteroids after the exacerbation Even a single dose of intravenous magnesium sulfate
can also decrease the relapse rate (140). administered to patients with severe acute asthma has
Inhaled or nebulized corticosteroids are not been shown to be effective.
currently recommended as being equivalent to sys- Based on current research, the dose for intravenous
temic steroids. Further studies examining differing magnesium sulfate is 25 to 75 mg/kg/dose up to 2 g
doses and routes of administration for corticos- in children, over 20 minutes (2, 135). Nebulized in-
teroids will clarify the optimal therapy, and the use haled magnesium sulfate in addition to beta-2 agonist
of corticosteroids within 1 hour of presentation to in the treatment of an acute asthma exacerbation also
2831_Ch13_307-354 13/03/14 3:32 PM Page 341
● Evidence in Practice 13-2 respiratory parameters (155). NIPPV might have a role
for pediatric patients with asthma and hypercapnic
Oral Magnesium (146) respiratory failure who do not require immediate intu-
A randomized controlled trial of oral magnesium bation, and it is frequently used in children’s hospitals
(300 mg/day) in 37 children ages 7 to 19 years found with anecdotal success. One retrospective study
that oral magnesium supplementation reduced reviewed the outcomes of pediatric patients placed on
bronchial reactivity to methacholine, diminished aller- NIPPV along with SABAs in the emergency depart-
gen-induced skin responses, provided better symp- ment. Of the patients placed on NIPPV, 88% tolerated
tom control, and reduced exacerbations in pediatric the therapy, and it prevented ICU admission in 22%
patients with moderate persistent asthma. Supple- of patients. Clinically, 77% showed an immediate
mental oral magnesium, or at least increased dietary improvement in respiratory rate after initiation of
intake of magnesium food sources (e.g., whole seeds, therapy, and 88% showed an increase in SpO2 (156).
grains, nuts, vegetables), may prove an effective ad- Most studies, particularly for severe asthma exacerba-
junctive therapy in asthma. Further research is required tions and very young pediatric patients (i.e., weighing
in different pediatric populations to confirm this finding, less than 20 kg), are small and retrospective, but they
and also larger studies in adults may be needed to have found NIPPV to be safe and that it may improve
determine whether this intervention has any merit. clinical outcomes (157).
A trial of NIPPV could be implemented in selected
patients with acute severe asthma in conjunction with
conventional medical treatment such as continuous
current therapies should be continued on a general nebulized SABAs and corticosteroids, but close
care pediatric floor. Patients will need immediate monitoring is required for the early recognition of
transfer to an ICU if they display the following symp- respiratory failure, such as decreasing levels of con-
toms after 60 to 90 minutes of aggressive therapy: sciousness. RTs should be readily available for these
patients, and intubation supplies and personnel
• FEV1 or PEF of less than 40%
should be close at hand to avoid delayed intubation
• PaCO2 greater than or equal to 42 mm
if NIPPV does not improve ventilation (135).
Hg
HELIOX
• Severe symptoms
A helium and oxygen mixture, known as heliox,
• Drowsiness or confusion
has been used to treat airway obstruction since 1934
One pediatric hospital reviewed their asthmatic ad- (158). Heliox has been studied and reported to be
missions and found that 85% of their ICU admis- effective in a variety of respiratory conditions such as
sions reported that the child had been previously upper-airway obstruction, status asthmaticus, decom-
admitted to the hospital for asthma (153). Additional pression sickness, postextubation stridor, bronchiolitis,
therapies should be available once a patient is in the and acute respiratory distress syndrome. Because
ICU. These include noninvasive ventilation, heliox, helium is an inert gas that is not known to interact with
intubation, mechanical ventilation, and inhaled anes- human metabolism, it can be used on any patient with-
thetics. Patients who fail mechanical ventilation and out adverse effects. Heliox is recommended as a useful
continue with severe airflow obstruction, hypoxemia, adjunct in patients with severe asthma, both for spon-
and hypercarbia may also warrant placement on taneous breathing and mechanical ventilation.
extracorporeal membrane oxygenation (ECMO). Helium is 86% less dense than room air. The only
NONINVASIVE POSITIVE-PRESSURE gas with a lower density is hydrogen, which is highly
VENTILATION flammable. As will be discussed in Chapter 15, the
Noninvasive positive-pressure ventilation (NIPPV) can lower density of heliox reduces areas of turbulence in
decrease the work of breathing by offsetting the intrin- the airways and increases laminar flow. Thus, heliox
sic positive end expiratory pressure (PEEP) caused by improves the efficiency of gas flow through narrowed
air trapping when patients are unable to completely orifices. Heliox decreases the work of breathing in
exhale during a severe exacerbation. The advantages patients with increased airway resistance, but it does
of NIPPV over intubation include improved comfort, not treat airway resistance. Rather, it reduces the in-
decreased need for sedation, decreased incidence of spiratory pressure required by the patient or ventila-
ventilator-associated pneumonia, and decreased length tor. When heliox was administered to seven patients
of ICU and hospital stay (154). On the other hand, with status asthmaticus intubated for respiratory
NIPPV carries an increased aspiration risk and failure, all patients experienced a significant reduction
requires increased monitoring and health-care staff in PaCO2, peak airway pressure, and increased tidal
resources. One randomized controlled trial involving volume within 20 minutes (159).
adults showed a benefit in the BiPAP group based on Heliox has also been used to deliver SABAs dur-
improvements in hospitalizations, discharge rates, and ing acute exacerbation. It increases the deposition of
2831_Ch13_307-354 13/03/14 3:32 PM Page 343
consumption and carbon dioxide production. Benzo- unload respiratory muscles and relieve fatigue (135). If
diazepines can be safely used to sedate a patient with a control mode is used, deep sedation and possibly
asthma, but time to awakening after discontinuation muscle paralysis is necessary to avoid patient-ventilator
is prolonged and difficult to predict. The most com- asynchrony and to manage controlled hypoventilation.
mon alternative is propofol, which is useful in patients Traditionally, volume-controlled ventilation has
with acute severe asthma of rapid onset who may be been preferred over pressure controlled. The per-
eligible for extubation within a few hours; the benefit ceived benefit is that alveolar ventilation may be
of propofol is that it can be titrated rapidly to a deep more consistent than with pressure controlled venti-
sedation level and has rapid reversal after discontinu- lation, mainly because of fluctuating and rapidly
ation. Propofol also possesses bronchodilatory prop- changing airway resistance and intrinsic PEEP. On
erties. The addition of an opioid (e.g., fentanyl or the other hand, volume-controlled ventilation man-
remifentanil) administered by continuous infusion dates careful monitoring of inflation pressures. How-
to benzodiazepines or propofol is often desirable to ever, no strong clinical data prove the superiority of
provide amnesia, sedation, analgesia, and respiratory any type or mode of positive pressure in status asth-
drive suppression (135). Ketamine is another anes- maticus, and barotrauma seems to occur regardless
thetic agent with strong analgesic action that mediates of the mode of delivery of positive pressure (169).
bronchodilation. Both of these properties make it a Volume ventilation settings would involve low
popular choice for children with severe asthma requir- tidal volume, avoiding a high respiratory rate and
ing mechanical ventilation (168). Once intubated, the maintaining an I/E ratio (inspiratory to expiratory
use of neuromuscular blockade may be necessary in time) of at least 1:3 (81). The inspiratory flow rate
patients with severe respiratory failure who are diffi- must be set higher to allow adequate expiration time.
cult to ventilate. Paralytics such as vecuronium and A higher inspiratory flow rate will result in higher
pancuronium decrease chest-wall stiffness, eliminate peak pressures. However, it is not the peak but the
patient-ventilator dyssynchrony, lower the risk of plateau pressure that has been associated with baro-
barotrauma, and decrease oxygen consumption (81). trauma. Plateau pressure (PPlat) should ideally be
MECHANICAL VENTILATION STRATEGIES kept at less than 30 cm H2O to reduce regional lung
Acute severe asthma will cause severe pul- over-stretch injury (170).
monary hyperinflation because of the marked limita- Although volume ventilation tends to be the mode
tion of the expiratory flow. Therefore, the main of choice, there are some downfalls. As tidal volume is
objective of initial ventilator management is twofold: delivered with constant flow in traditional volume-con-
to ensure adequate gas exchange and to prevent further trolled ventilation, relatively less obstructed airways
hyperinflation and ventilator-associated lung injury. with shorter time constants are likely to receive more
This may require permissive hypercapnia, or de- volume throughout inspiration compared to more
liberate hypoventilation and acceptance of obstructed airways with longer time constants. This
higher PaCO2 levels and a more acidic pH. Permis- would result in uneven ventilation, higher peak inspi-
sive hypercapnea provides adequate oxygenation and ratory pressure, and a decrease in dynamic compliance.
ventilation while minimizing high airway pressures With pressure control ventilation (PCV), because of a
and barotrauma. Specifically, it involves administra- constant inflation pressure, relatively fewer obstructed
tion of fractional concentration of inspired oxygen lung units with shorter time constants would achieve
(FIO2) at a value that is as high as necessary to main- pressure equilibration earlier during inspiration com-
tain adequate arterial oxygenation, acceptance of pared with more obstructed areas. Thus, units with
hypercapnea, and treatment of combined metabolic shorter time constants would attain their final volume
and respiratory acidosis with intravenous sodium earlier in inspiration, whereas those with longer time
bicarbonate (2). constants would continue to receive additional volume
No randomized controlled trials have been com- later in inspiration. This would result in a more even
pleted to determine the best ventilation mode in life- distribution of inspired gas, delivery of more tidal vol-
threatening asthma. The chosen mode is probably less ume for the same inflation pressure, and improved
important than providing settings that minimize dynamic compliance. One hospital’s study of 40 chil-
dynamic hyperinflation and intrinsic PEEP caused by dren admitted for 51 episodes of severe status asth-
increased airway resistance. Monitoring lung mechan- maticus over 5 years assessed the effectiveness of PCV
ics is of paramount importance for the safe ventilation as the chosen ventilation mode. The studied popula-
of patients with status asthmaticus. Following intuba- tion had a low incidence of barotrauma, lower dura-
tion, controlled modes of ventilation are usually tion of ventilation, and blood gas improvement
employed. The exhaustion of respiratory muscles after immediately upon initiation (171).
spontaneous breathing against a heavy resistive load With either pressure or volume ventilation,
of bronchoconstriction makes the assist-controlled the recommendations for respiratory rate,
mode a reasonable choice in the first 24 hours to I/E ratio, FIO2, and PEEP are the same.
2831_Ch13_307-354 13/03/14 3:32 PM Page 345
Asthma deaths are rare among children and increase Intramuscular Versus Intranasal
with age. In 2007, 152 children younger than 15 years
died from asthma (0.2 per 100,000 population) com- Influenza Vaccinations for Infants
pared to 659 adults older than 85 years (6). A 2012 With Wheezing/Asthma (175)
retrospective review of pediatric intensive care unit
(PICU) data from 2004 to 2008 showed that the Influenza is a highly infectious disease caused by
death rate of children admitted to PICUs with a pri- viruses. Influenza has been thought to cause asthma
mary diagnosis of acute asthma was 0.3%, making attacks. Few trials have been carried out to test
it a very rare event (163). Children with asthma who whether asthma attacks following influenza infection (as
live in high-poverty communities have disproportion- opposed to following the vaccination) are significantly
ately high adverse asthma outcomes. There are racial reduced by having been vaccinated, so uncertainty
disparities for asthma in ED visits, hospitalizations, remains in terms of the difference vaccination makes to
and death, which are substantially higher than preva- people with asthma. The included studies suggest that
lence disparities alone (2). the vaccine against influenza is unlikely to precipitate
asthma attacks immediately after the vaccine is used.
Hospitalizations
Asthma is classified as a condition for which hospital-
ization is preventable, yet it continues to have a high
annual rate of hospitalization, particularly for chil- asthma remains a leading cause of hospitalization
dren. The most common reasons for the preventability among children. Two-thirds of children with known
of asthma hospitalizations cited are usually parent asthma were hospitalized for an exacerbation that
and patient related. Medication-related issues were had been consistently poorly controlled during the
identified, which included adherence problems, med- previous year, 69% of them had at least one prevent-
ications not being given soon enough, families run- able risk factor for hospitalization, and more than
ning out of medications, and refills not being called in 75% had asthma that was not well controlled in the
to pharmacies. Inadequate preventive measures was month before hospitalization. These results point out
another reason frequently identified; this consisted of the high proportion of poorly controlled asthma in
failure to avoid known triggers of the child’s asthma children without adequate controller therapy (60% of
exacerbations, including exposure to cigarette smoke them did not have any controller medication, or they
(the most often cited in this subcategory), household had only low-dose ICS) despite the long-standing
dust, other children with upper respiratory infections, nature of this poor control and thus suggest a sub-
and pet dander, such as allowing a child who is allergic stantial potential for improvement (176).
to dogs to play with a puppy (174). The United States has found similar issues with pe-
In a 2011 retrospective study of pediatric patients ad- diatric hospitalizations. One 2009 national study found
mitted to an ICU for asthma exacerbation, 67% were considerable variation in pediatric asthma hospitaliza-
readmitted to the hospital following discharge from tion rates by and within states, suggesting that the use
the initial admission and 16.6% were readmitted to the of national hospitalization rates to develop public
ICU. Of the total children studied, 1.8% of them died health intervention policies may not target the popu-
from asthma within 10 years of ICU discharge (9). lations most at risk (177). The study’s findings indicate
At times, asthma can be a predictor of additional a significant difference in the overall pediatric asthma
health-care burden and a coexisting factor for hospi- hospitalization rates ranging from 51.1 per 100,000
talizations for other respiratory diseases. In a surveil- children in Oregon to 185.9 in Kentucky. These rate
lance of 10 states during the 2003 to 2009 influenza differences persist even when examining geographic
seasons, 32% of children hospitalized with influenza subcategories, and there is no consistent pattern across
had asthma; during the 2009 pandemic, 44% of chil- states when examining rurality. For example, Florida
dren had asthma. The median age of the children was children living in urban areas are most likely to be hos-
7 years, and 73% had no additional medical condi- pitalized for asthma, whereas in Kentucky and
tions (11). This stresses the importance for annual Oregon, children living in rural counties are most likely
influenza vaccinations and pandemic influenza vac- to be hospitalized (177). These findings support efforts
cinations (175). (Special Populations 13-2). to increase health insurance coverage for children,
In France, half of all hospitalizations for asthma which may also improve access to prescription drugs
occurred among children, and their hospitalization that can help manage asthma exacerbations.
rates, contrary to those of adults, have not decreased
over the past decade. Despite improvement in asthma Cost of Asthma
management, including treatment and health educa- From 2002 to 2007, the total incremental cost of
tion, adherence to guidelines remains poor, and asthma for a single patient was estimated to be $3,259
2831_Ch13_307-354 13/03/14 3:32 PM Page 347
begin that therapy. You arrive back in the triage shots, and so she has stopped that part of her
area and show Amanda how to use the MDI along therapy. An aunt has been teaching her about
with a holding chamber. You provide her with six herbal therapies for asthma, and so she has been
puffs of albuterol, and stay to monitor her for the taking propolis, vitamin C, and magnesium supple-
next 20 minutes before administering additional ments daily. She has a PFM at home but only uses
therapy. While you wait, you ask Amanda’s mom it when she experiences symptoms, and she
for additional history. Amanda has twin 12-year-old hasn’t had an exacerbation or needed her SABA
brothers, who are very healthy and active, and no in the last 6 weeks. She also admits to you that
one in the family has allergies or asthma. Amanda often when she’s working she does not remember
has always had lots of runny noses and upper res- to take her diskus before going to bed at night.
piratory infections, which seem to take longer for You do a PEF with her and she is at 90% of her
her to recover from than the other family members, personal best, and says she’s experiencing no
and they often cause her to cough when no one symptoms. Her breath sounds are clear bilaterally,
else has that symptom. She’s been to urgent care and pulse rate is 98 bpm.
twice this winter for difficulty breathing and a cough
• Based on the information you’ve gathered,
that keeps her up at night. The nurse practitioner at
how well do you think Samantha’s asthma is
the urgent care center recommended that Amanda
controlled? Would you make any recommen-
be seen by her pediatrician, but Amanda has been
dations for change in her control therapy?
so busy with dance classes and other family activi-
• Would you have any recommendations or
ties they just haven’t had time to go.
comments on her use of alternative therapies?
• Based on her symptoms and history, do you
■ Case 3: Andy Singh
think Amanda has asthma?
You are an RT working in a children’s hospital in the
Amanda is given eight puffs of albuterol every pediatric ICU. You receive a call from the emer-
20 minutes and is given one dose of oral corticos- gency department that they will be transferring
teroids—she is able to perform a PEF afterward Andy Singh to the PICU. Andy is a 10-year-old
with 60% of predicted value and vital signs are HR, who has been in the PICU twice before for status
158 bpm; SpO2,increased to 97%; BP, 100/60; asthmaticus. He is diagnosed with moderate per-
and she continues to have inspiratory and expira- sistent asthma but has a high risk for severe airway
tory wheezes. One hour later her dyspnea and PEF limitation during his exacerbations. He has received
is unchanged, so the on-call pediatrician agrees to 2 hours of continuous nebulized albuterol in the
admit her overnight for observation and continued ED, along with one dose of IV magnesium and IV
bronchodilator therapy. corticosteroids. His PEF rate is 40% of his personal
best. He was trialed on heliox with his continuous
■ Case 2: Samantha Ocee
nebulizers, but his SpO2 had dropped to 88% so
You are the RT working in an asthma and allergy
he was switched to FIO2 1.0. The ED RT just
clinic in a large town. You are seeing Samantha
placed him on BiPAP with an inspiratory positive
Ocee, a 16-year-old patient who was diagnosed
airway pressure of 15 cm H2O and an expiratory
with asthma at 4 years old. She is here for her an-
positive airway pressure of 5 cm H2O. His ABG
nual follow-up examination. Samantha is a
values 30 minutes after BiPAP initiation is
healthy-looking teenager who has allergic asthma
7.10/88/65/24.3. Andy is beginning to become
and up until 6 months ago was receiving im-
less responsive and sleepy, and though he had
munotherapy twice a week for her outdoor allergy
audible bilateral wheezes, his breath sounds are
triggers. She was diagnosed at her last visit with
becoming diminished. His vital signs are HR,
moderate persistent asthma, and her control ther-
135 bpm; RR, 35 breaths/min; SpO2, 89%; and
apy includes a fluticasone/salmeterol diskus twice
BP, 100/50 mm Hg (dropping to 80/50 mm Hg
a day and an albuterol SABA for acute symptoms.
during inspiration).
You go into the room to discuss her asthma symp-
toms and quality of life with her. Samantha tells • What should be the next recommended
you that she recently got her driver’s license and is course of action for Andy?
working after school three evenings a week and • What would you recommend as initial ventila-
on the weekends as a hostess at a local restau- tor settings? Would you continue with the
rant. She no longer has time to get her allergy same bronchodilator therapy after intubation?
2831_Ch13_307-354 13/03/14 3:32 PM Page 349
Multiple-Choice Questions
1. Which of the following would not be a risk c. Nighttime awakenings more than twice per
factor for developing asthma? month
a. Growing up on a farm d. Limited activity levels
b. Being a boy 6. How frequently can patients who are having an
c. Having a poor health history acute exacerbation at home take a SABA?
d. Having a grandfather with asthma a. 0 to 15 mg/kg every 20 minutes nebulized
2. What are the four main characteristics of for three doses, then 0.15 to 0.3 mg/kg every
asthma? 1 to 4 hours
I. Airway edema b. 4 to 8 puffs SABA every 20 minutes for up
II. Bronchoconstriction to 4 hours
III. Airway hyperresponsiveness c. 10 puffs every 30 minutes for up to 4 hours
IV. Atopy d. 2.5 mg/kg every 4 hours
V. Increased mucus production 7. At what point should a patient with an acute
VI. Airway remodeling exacerbation go for emergency medical care?
a. I, II, III, IV a. PEF less than 50%
b. I, II, V, VI b. PEF 50% to 79%
c. II, III, IV, VI c. PEF 40% to 60%
d. I, II, III, VI d. PEF less than 40%
3. Which of the below signs and symptoms 8. Which of the following is/are no longer consid-
should make a clinician suspect a diagnosis ered appropriate emergency room treatment(s)?
of asthma? a. Magnesium
I. Wheezing b. Mucolytics
II. Nighttime coughing c. Heliox
III. Allergic rhinitis d. Continuous SABA
IV. Symptoms that worsen with viral
infections 9. You are caring for an intubated patient in
V. Symptoms that occur in the presence status asthmaticus who is sedated and is not
of pets taking any spontaneous breaths. You note that
a. I, II the flow waveform is not returning to zero after
b. I, II, III each breath. Which of the following ventilator
c. I, II, IV, V changes might offer additional time for
d. I, II, III, IV, V exhalation?
I. Decrease I-time
4. Classify the asthma severity of the following II. Increase I-time
patient: A 7-year-old with asthma symptoms III. Increase RR
three to four times a week for which she uses a IV. Decrease RR
SABA inhaler. She is awakened a few times a V. Inverse I/E ratio
month with coughing and wheezing, occasion- a. II, III, V
ally has to sit out at recess for difficulty breath- b. I, IV
ing, and has had two exacerbations this year c. II, IV
that required oral corticosteroids. d. I, III
a. Intermittent
b. Mild persistent 10. Which of the following is a recommended
c. Moderate persistent method for corticosteroid therapy for a
d. Severe persistent 6-month-old?
e. Does not have asthma a. Beclomethasone
b. Budesonide
5. Which of the following are symptoms of c. Fluticasone
poorly controlled asthma? d. Oral prednisone
a. FEV1 60 to 80%
b. FEV1/FVC 80 to 90%
2831_Ch13_307-354 13/03/14 3:32 PM Page 350
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Chapter 14
355
2831_Ch14_355-380 13/03/14 3:30 PM Page 356
Chapter Objectives
After reading this chapter, you will be able to:
1. Identify the two major body systems affected by cystic fibrosis and the subsequent clinical manifesta-
tions that affect them.
2. Describe the process for screening and diagnosing cystic fibrosis.
3. Describe six methods of airway clearance available for patients with cystic fibrosis.
4. Recommend inhaled therapies for a patient with cystic fibrosis based on clinical signs and symptoms.
5. Create a daily treatment schedule for a patient with cystic fibrosis.
6. Identify common organisms that contribute to pulmonary exacerbations.
7. List several common complications that manifest during the progression of cystic fibrosis.
80
Percent of patients
60
40
20
0
⬍2 2–5 6–10 11–17 18–24 25–34 35–44 45⫹
Age (years)
Sinuses:
frequent infections,
sinusitis, polyps
Lungs:
thick secretions, Skin:
airway obstruction, salty sweat
bronchiectasis, (⬎60 mmol/liter)
hemoptysis,
pneumothorax
Liver:
Pancreas:
obstructive biliary
enzyme insufficiency,
tract disease
blocked pancreatic
ducts, insulin-dependent
Intestine: diabetes mellitus
intestinal blockage
(meconium ileus),
poor nutrient
absorption, Reproductive
constipation, organs:
rectal prolapse infertility
Figure 14-3 Manifestations of Cystic
Fibrosis
index (BMI) have better lung function (Fig.14-4) chronic respiratory symptoms varies and cannot be
(11). Although these data do not demonstrate a easily predicted. The inability to forecast the timing
causal relationship, it suggests that patients should of the development of future respiratory problems
strive to maintain a normal BMI. can be very stressful for families. Although older chil-
dren with worse lung function tend to have more
Pulmonary Manifestations cough and sputum production, these symptoms can
Obstruction of the small airways by viscous secre-
tions is associated with infection and inflammation
that eventually lead to bronchiectasis and mucus
plugging (Figs. 14-5 and 14-6). Infants and young
children with CF typically have few, if any, respira-
tory symptoms when adequately treated. However,
ongoing airway damage eventually leads to chronic
cough and sputum production. The progression to
100
FEV1 percent predicted
90
80
Goal Males
50th percentile Females
70
60
⬍5 10 20 30 40 50 60 70 80 90
BMI percentile
Figure 14-4 Relationship Between Lung Function (FEV1)
and Nutritional Status Measured by Body Mass Index
(BMI) (From the 2010 Patient Registry Report, CF Foundation, Figure 14-5 Bronchiectasis (Courtesy of Peter Mogayzel Jr.
Bethesda, MD; with permission) MD, PhD, MBA)
2831_Ch14_355-380 13/03/14 3:30 PM Page 359
Box 14-1 Annual Care, Screening, and easily transport mucus up and out of the airways
Prevention Guidelines puts patients at higher risk for respiratory infection
and airway inflammation.
• Four or more clinic visits per year ACTs enhance secretion mobilization and thereby
• Four or more respiratory cultures minimize airway obstruction, infection, and inflam-
• Two or more PFTs if 6 years of age or older mation. Improving ventilation and using expiratory
and physically able airflow are the keys to a good airway clearance strat-
• An influenza vaccine if 6 months of age or older egy. Many different treatment techniques can be
• Measurement of fat-soluble vitamin levels employed, and the decision to use a particular strat-
• An oral glucose tolerance test if 10 years of age egy should be based on clinical findings as well as the
or older patient’s preference. Systematic reviews have estab-
• Measurement of liver enzymes in the blood lished the short-term effectiveness of various ACTs
but have not found conclusive evidence to suggest
that one strategy is superior to the others (16, 17).
(Evidence in Practice 14-1)
Pulmonary management of CF relies on daily pre-
scribed management to improve airway clearance and Postural Drainage, Percussion, and Vibration
lung function, as well as early treatment of any pul- The most common form of airway clearance for in-
monary infections or exacerbations to prevent perma- fants in the United States includes postural drainage,
nent declines in lung function and quality of life. Daily percussion, and vibration (2). Postural drainage uses
therapy includes airway clearance techniques, exer- gravity to mobilize mucus from different lung seg-
cise, inhalation therapies, and infection control. ments. Patients are positioned to anatomically target
Treatment of pulmonary infections and exacerbations specific lung segments and drain mucus from the
includes many of the same techniques, but will require lung periphery into the more central airways. Tradi-
an increase in the timing or mode of therapy to im- tional postural drainage uses 6 to 12 different posi-
prove symptoms and clear the offending cause. tions that tip the head and chest downward to drain
mucus from the lung fields. This technique can be
Airway Clearance modified for any patient, regardless of age or disease
Airway clearance techniques (ACTs) are an essential severity. The modified technique, which is more com-
part of the daily treatment and management for in- monly used, employs 4 to 6 positions that don’t tip
dividuals with CF (Table 14-2). Airway clearance is the head and chest downward (Fig. 14-7) (21).
typically performed in conjunction with inhalation Percussion is performed over the lung segment
therapies (discussed later in this chapter). As noted being drained to loosen mucus from the airway
previously, CF airways produce an excessive amount walls. The technique involves cupping the hands and
of thick, sticky mucus that is difficult to mobilize and rhythmically clapping over the chest wall. The fre-
that impairs mucociliary clearance. The inability to quency of clapping transmits an energy wave that
Postural drainage, M M Y Y Y Y
percussion, and
vibration
HFCWO N Y Y Y Y Y
ACBT N N Y Y Y Y
PEP M M Bubble PEP Y Y Y
Oscillating PEP N N As adjunct Y Y Y
Autogenic drainage M M M Y Y Y
Breathing games N Y Y Y Y Y
IPV N N N Y Y Y
Exercise Y Y Y Y Y Y
Y indicates yes; N, no; M, modified technique can be employed.
2831_Ch14_355-380 13/03/14 3:30 PM Page 361
● Evidence in Practice 14-1 loosens mucus from the airway walls. The action is
similar to the effect created when you clap the bot-
When to Begin Airway Clearance tom of a ketchup bottle to get the liquid flowing.
The wide availability of newborn screening for CF Vibration is generated by gently shaking the chest
means that the patients are now often diagnosed wall during expiration with your hands or a mechan-
prior to the onset of overt pulmonary disease. The ical device. This helps mobilize secretions by oscillat-
question of whether to begin ACT with a newly di- ing the airways and increasing expiratory flow rates.
agnosed infant is a topic of much discussion in the These techniques can be used at any age, and
international CF community. Clinicians favoring the they can focus treatment on the problematic lung
“wait to treat” viewpoint argue that ACT should be segments. The disadvantages of postural drainage,
delayed until the infant begins to show respiratory percussion, and vibration are that they cannot be
symptoms. They would argue that treatment at an performed independently because they require a
early age is an unnecessary burden for the family caregiver to perform them, and they take a long time
and that aggressively performed ACT, such as per- to adequately treat all lung segments. Airway clear-
cussion and vibration, may evoke a negative re- ance in individuals with gastroesophageal reflux
sponse in the infant. Potential side effects such as (GER), which is common in patients with CF, can
gastrointestinal reflux and overstimulation could be potentially cause more harm than good. Evidence
detrimental to the infant’s overall health. suggests that the effects of postural drainage are
On the pro side of the early initiation of ACT argu- detrimental for people with GER (21) because air-
ment is that preserving lung function in infants with CF way inflammation can result from aspiration of
is one of the primary goals of disease management. acidic stomach contents into the airways. This prob-
Advocates for commencing airway clearance at diag- lem has been well studied in young children. For ex-
nosis point to studies demonstrating the presence of ample, a long-term study demonstrated statistically
lung damage prior to the onset of any clinical symp- greater lung function decline and radiological
toms. For example, bronchoalveolar lavage (BAL) changes by age 5 years in children with GER using
studies in infants with CF with stable and or clinically head-tilted-down postural drainage positions versus
mild lung disease found inflammatory changes in even children who did not (21). For this reason, modified
the first weeks of life (18). The CF clinics in Australia postural drainage positions that do not tip the child’s
introduced a microbiological surveillance program head down are now the standard of practice when
using bronchoscopy and BAL annually on infants and using manual percussion and drainage in all children
young children with CF until they are able to expecto- with CF who are younger than 2 years. Some evi-
rate sputum (19). These investigators found that al- dence also suggests that head-down positioning in
though 84% of the infants were asymptomatic, 21% older children and teenagers with CF can also aggra-
of infants diagnosed with CF by newborn screening vate GER, but there is no conclusive evidence in
were infected on BAL at diagnosis. Sly et al (19) also adults (22). Based on the current evidence, many cli-
demonstrated abnormal radiographic abnormalities nicians have stopped employing head-down postural
indicative of lung disease in 81% of the 57 infants with drainage positioning in any patient with CF.
CF with a median age of 3.6 months. Even more con- Additional airway clearance options for infants
cerning is the fact that these lesions progressed over include modified autogenic drainage and infant pos-
time (20). Thus, it is clear that the lungs may be un- itive expiratory pressure, both of which are discussed
dergoing damage before the first clinical symptoms later in this chapter.
appear. Initiating ACT from the time of diagnosis also High-Frequency Chest Wall Oscillation
enables the family to establish a routine from the start.
This builds a solid foundation and establishes the Maintaining a regular airway clearance program for
importance of ACT as a therapy that will be part of toddlers can pose a problem for many parents. Tod-
everyday life for every child with CF. dlers are developing their sense of independence and
Advocates of early institution of airway clearance adventure and often do not like to be contained for
argue that the benefits far outweigh the risks. Over- ACTs. They may resist the efforts of the caregiver to
all the evidence supports the argument for earlier in- provide treatment and may not sit still for modified
tervention because symptoms alone cannot predict postural drainage and percussion. Families some-
the damage occurring in the infant’s airways. Infants times express concern over not being able to provide
cannot be traditionally tested for lung function, and adequate treatment to their child. One possible so-
specialized tests are not readily available to all pa- lution to this dilemma is the use of high-frequency
tients. Therefore, many feel it is best to aggressively chest wall oscillation (HFCWO), which uses an in-
treat and prophylactically assist with airway clear-
flatable jacket with an air pulse generator that rap-
ance and infection prevention.
idly fills and deflates the jacket at a set pressure. Both
frequency and pressure are adjustable. Examples
2831_Ch14_355-380 13/03/14 3:30 PM Page 362
(extraluminal pressure) (Fig. 14-9). Extraluminal This series of three huffs should be incorporated
pressure typically remains constant while intralumi- into most ACTs.
nal pressure changes as one inhales and exhales. Air- The series of huffs just described is not always
way pressure gradually increases during inhalation necessary. However, many patients may have secre-
and then decreases during exhalation. With a deeper tions in the larger airways and would benefit from
inspiration, the pressure in the distal airways will in- a FET with large inspiratory volume. As with all
crease even more. As the pressure decreases during ACTs, the huffing portion should be individually
exhalation, there will be a point at which intraluminal tailored to the patient’s needs.
and extraluminal pressures are the same, which is the ACTIVE CYCLE OF BREATHING
EPP. Just proximal to the EPP (closer to the mouth) The ACB is a basic breathing exercise that is easy to
there will be a slight compression of the airway. It is teach and easy for patients to learn. Generally, ACB
this compression, or squeezing, of the airways that can be effectively introduced to school-aged chil-
helps to move secretions from the distal airways. dren. ACB is adaptable to various treatment settings
ACTs also take advantage of collateral ventila- and can be combined with other ACTs, such as man-
tion, which is present throughout the lung. Using ual postural drainage and HFCWO.
interbronchial and bronchoalveolar connections, or During ACB, patients cycle through three types
channels, air is able to spread throughout the air- of breathing (Fig.14-10):
ways, behind any mucus blockages. Many ACTs in-
• Breathing control (i.e., normal, ideally
corporate an inspiratory hold, lasting 2 to 3 seconds,
diaphragmatic)
to use collateral ventilation to open distal airways
• Thoracic expansion
and alveoli as well as allow air to get behind the
• FET
mucus to help move it closer to the mouth.
To perform a FET, the patient should take a Patients should always start ACB using their nor-
small breath in, followed by an inspiratory hold to mal breathing pattern. When ready, thoracic expan-
allow for collateral ventilation. The small breath sion breaths are performed. The practitioner can
in leads to the EPP being more distal and is thus provide a tactile cue to facilitate this deep breathing
more likely to mobilize mucus from the small air- (e.g., hands on the lower rib cage to facilitate lateral
ways. The exhalation should be fast enough to costal expansion). Hand placement provides propri-
overcome airway resistance, but not so fast as to oceptive stimulation to increase ventilation to a
create airway collapse. A general guideline to teach certain part of the lung. At most, three to four expan-
patients is that they should not hear any harsh or sion breaths should be performed. These expansion
wheezing noises during exhalation. The next huff breaths should always be followed by breathing con-
should be with a medium, or slightly larger than trol, at least three to four breaths, but more can be
tidal volume, inspiration. The third breath in performed if needed to recover from the deeper
should be large, approaching inspiratory reserve breaths. This cycle should be repeated until the
volume, to mobilize the mucus into the larger, cen- patient or therapist hears or feels that mucus has
tral airways. Each of these breaths should be fol- loosened. At this point, a series of huffs should be
lowed by an inspiratory hold and a forced expiration. performed. Coughing should occur if mucus has
moved into the central airways. If the patient does
not feel the need, the cough should not be forced. The
0 mm Hg huff and cough should be followed by relaxed breath-
⫹5
ing. The whole cycle is then repeated.
⫹10
BC
⫹20 BC TEE
Equal pressure point BC BC TEE HUFF
TEE
⫹25 HUFF HUFF BC
⫹30 BC BC
BC HUFF
HUFF TEE
BC
important to use a face mask or nose clip with any The oscillating PEP devices differ slightly in
patient who cannot maintain mouth breathing with their function and design. The most unique oscil-
a tight seal over the mouthpiece for the series of lating PEP device is the Flutter. This device uses
breaths. As with other ACTs, huffs follow each se- the benefits of oscillations more than its PEP fea-
ries of breaths to mobilize and assist with clearing ture. The frequency of the vibrations depends on
the secretions before the cycle is repeated. the angle that the device is held in the mouth. It is
PEP may be a particularly useful ACT for pa- necessary to incorporate an inspiratory hold to
tients who have an asthma component to their res- allow time for collateral ventilation to get air into
piratory disease because it prevents collapse of previously obstructed airways and alveoli. The
narrowed airways (27). In this CF subgroup, the re- Flutter does not provide as much PEP as other de-
active airway collapsibility can trap mucus in the vices, so it does not provide the increase in FRC
airways. The airway stenting feature of PEP stabi- found in the closed system of PEP devices or the
lizes the airway and allows air to use collateral ven- acapella device.
tilation channels to travel down behind the mucus The acapella has more PEP features than does
so it can be mobilized. the Flutter. The oscillatory frequency of this device
PEP is also being used for infants at some CF cen- is not angle dependent, and it has an expiratory
ters. Infants do not have well-developed collateral flow option of greater than 15 L/min (Fig. 14-11).
ventilation channels, but they can still benefit from The acapella also has an option for lower flows that
the temporary increase in FRC through the principle may be more suitable for younger children and
of interdependence. The temporary increase in air patients with poorer lung function. A dial controls
volume in the lungs allows healthy alveoli to create the amount of PEP and frequency of vibrations.
an outward pull on deflated alveoli to re-expand ob- Increasing the PEP will decrease the frequency of
structed airways. Better aeration throughout the vibrations. Turning the dial in the other direction
lungs reduces the chances of infection and inflam- increases the oscillatory benefits of the acapella by
mation by limiting hypoxia in previously collapsed decreasing the PEP.
portions of the airways. The instructions for use of oscillating PEP follow
The PEP technique is modified for use in infants. those for its PEP counterpart. Slightly larger than
The baby is held and a small infant PEP mask is held tidal volume breaths are performed in cycles of 10
over the infant’s mouth and nose for 10 to 15 breaths. to 15 breaths with breath holds. This is followed by
Midexpiratory pressures are expected to be 3 to 5 cm huffing and coughing, then breathing control, be-
H2O for infants, as compared to 10 to 20 cm H2O fore repeating the cycle. Total treatment time
used with older children and adults. The goal is to should be 15 to 20 minutes, and it is usually pre-
optimize lung aeration. The other difference for in- scribed twice daily; however, as with other ACTs,
fants using PEP is that they cannot perform a FET the program should be individualized to the pa-
on their own. Therapists can use techniques to stim- tient’s needs.
ulate a cough or FET, such as part of the assisted
autogenic drainage technique, discussed later.
Oscillating PEP
Oscillating PEP is a subtype of PEP most commonly
used by clinicians in the United States (2). These de-
vices, which can be introduced to school-aged chil-
dren, include the acapella (Smiths Medical, Dublin,
OH); Flutter (Aptalis, Birmingham, AL); Quake
(Thayer Medical, Tucson, AZ); and RC Cornet
(R. Cegla GmbH & Co. Montabaur, Germany).
Oscillating PEP devices combine PEP with high
frequency expiratory oscillations (25). The flow-
dependent oscillations created in addition to the PEP
are theorized to act similarly to vibrations created by
HFCWO devices. They help decrease sputum vis-
cosity and can improve ciliary beat via resonance if
the correct oscillating frequency is established. The
vibrations create continuous interruptions of expira-
tory airflow, allowing waves of positive pressure to Figure 14-11 Oscillating PEP. Teenage patient with CF
mobilize secretions and facilitate their progression up using an acapella® oscillating PEP device. (From Johns
the airway. Hopkins University, www.hopkinscf.org; with permission)
2831_Ch14_355-380 13/03/14 3:31 PM Page 367
■ ■ At the end of Ryan’s first appointment, his expiratory flow rates. Encouraging climbing activi-
parents are instructed in the use of modified percus- ties and upper-body strength with activities such as
sion and postural drainage. The hallmark of CF is the going across monkey bars and performing wheel-
presence of abnormal, viscous secretions within the barrows will improve breathing mechanics by opti-
airways. Airway clearance techniques that promote mizing chest/respiratory accessory muscle strength
mobilization of airway secretions are the cornerstone and flexibility.
of chronic CF therapies. Although Ryan has no respi- School-aged children and teens often enjoy partic-
ratory symptoms, he still has viscous secretions, and ipation in more organized individual and team ath-
his parents are told that airway clearance should be letics. Activities such as dance, gymnastics, yoga,
performed twice daily. martial arts, bicycling, hiking, and team sports are
great ways to get children active and exercising. Chil-
dren who are more inclined to video games and com-
puters may benefit from using interactive gaming
Exercise systems to increase their activity. There are a multi-
Exercise is an important adjunct to airway clearance. tude of games that encourage cardiopulmonary fit-
Physical activity can increase minute ventilation and ness as well as posture and good breathing mechanics
expiratory air flow. The improved ventilation can (Teamwork 14-1).
open previously collapsed airways and get air behind
mucus plugs. The expiratory air flow increase will Inhalation Therapies
help shear mucus from the airway walls so it can be A common part of a patient’s everyday routine
moved centrally up the airways for clearance. Exer- includes inhaled medications. These treatments are
cise as an adjunct to therapy should incorporate used to prevent the buildup of thick, sticky mucus;
huffing and/or coughing to assist with mucus clear- manage infection; and help preserve lung function
ance. There is no evidence that supports exercise as over time. Table 14-3 lists inhaled medications fre-
a stand-alone ACT, but many studies support the quently used by patients with CF. It is important to
overall improvement in respiratory function. remember that not all patients receive all of the med-
As infants develop, facilitation of movement and ications available. Individualized treatment plans
exercise can also be used for airway clearance. Ven- should be developed based on the patient’s age,
tilation distribution can also be affected by altering symptoms, and severity of lung disease. Evidence-
the child’s positioning and/or breathing pattern with based guidelines for the use of these therapies have
selected activities. Certain movements or activities been published and can aid in treatment decisions
can cause a change in breathing pattern that mimics (30). These guidelines provide recommendations of
some of the breathing exercises that will be intro- effective therapies for children older than 5 years
duced when the child is older. For example, bounc- and adults with CF. Unfortunately, they do not
ing with a parent or caregiver on a therapy ball or provide guidance on when to start a particular ther-
on the caregiver’s lap can increase expiratory airflow apy or identify the best combinations of therapies.
and simulate huffs. Although these therapies are often used in younger
Challenging the baby to pull up and use shoulder children and may in fact be effective, there is not
muscles and core abdominal muscles can create enough evidence to recommend their use in children
breath holds and releases. Additionally, activities younger than 5 years.
and games that promote arm and trunk mobility, The daily treatment routine of inhaled medications
such as raising an infant’s arms overhead in a “so and airway clearance can be burdensome to patients
big” gesture, will optimize lung function through im- and families; however, it is important that patients
proved chest wall flexibility. Exercise can play a vital adhere to these therapies to have the best chance of
role in airway clearance in infants. It is practiced as preserving lung function. Respiratory therapists can
a staple for CF management in Sweden. In fact, The provide encouragement, education, and support to
Lund CF Centre in Sweden has adapted exercise/ patients and families regarding these inhaled treat-
activity as the infant’s primary mode of airway clear- ments and explain the importance of remaining com-
ance and has not used postural drainage or percus- pliant with them.
sion with any of their patients since 1983 (29)
Games introduced to the infant and toddler can Bronchodilators
be expanded on with the preschooler. Incorporat- Bronchodilators, such as albuterol or levalbuterol,
ing hippity-hop balls, trampolines, and riding toys are often used before ACTs to increase the caliber
can be fun ways to increase the exercise and activity of the airway and improve mucociliary clearance.
necessary for the health of a child with CF. Such A bronchodilator can also be routinely administered
activities will also promote breathing patterns before hypertonic saline and other inhaled medica-
that can facilitate mucus clearance via increasing tions to prevent bronchospasm. Many patients with
2831_Ch14_355-380 13/03/14 3:31 PM Page 369
Table 14-3 Common Inhaled Medications for discusses and believes that introduction of nebulized
Patients with CF therapy to thin the airway secretions would be
worthwhile as an addition to Ryan’s daily ATCs.
Bronchodilators Mucolytics Antibiotics
of use of dornase alfa in treating atelectasis in • Colistin: a polymyxin antibiotic that disrupts
patients without CF, there is not enough evi- the outer bacteria cell membrane.
dence to recommend it routinely for this use.
Side effects
• Hypertonic saline: Inhaling saline with a high
• Tobramycin: Sore throat, voice changes, and
concentration of salt (typically 7%) acts to re-
redness around eyes
hydrate the dehydrated airway secretions by
• Aztreonam: Cough, nasal congestion, and
drawing water into the airways to replenish the
wheezing
airway surface liquid. Hypertonic saline also
• Colistin: Cough, wheezing, and chest tightness
has the benefit of inducing a cough in many
patients. Inhaled antibiotics frequently are used to eradi-
cate P. aeruginosa when it is first cultured, even when
Side effects
children are asymptomatic. Recent studies have
• Dornase alfa: Sore throat, voice changes, and
shown that 28-day course of inhaled antibiotics is
eye irritation
very effective at eradicating P. aeruginosa (34, 35).
• Hypertonic saline: Bronchospasm, salty taste
The Eradication of Pseudomonas Infection Control
and burning feeling in mouth/throat
(EPIC) trial found that the addition of 14 days of
N-acetylcysteine, which breaks disulfide bonds, oral ciprofloxacin to 28 days of inhaled tobramycin
has been used as a mucolytic for many years, but did not improve the eradication rate of P. aeruginosa
there is not enough research evidence to recommend (35). Ratjen et al (34) demonstrated that 56 days of
its routine use in patients with CF (26). Studies of inhaled tobramycin was no more effective at eradi-
inhaled mannitol used to hydrate airway secretions cating the P. aeruginosa when compared to 28 days
in patients with CF suggest that this medication is of therapy. Both therapies were able to eradicate the
effective (31, 32). However, this medication is not yet infection in greater than 92% of children. The use of
approved for use in the United States. routine administration of inhaled antibiotics with
or without oral antibiotics does not appear to de-
Inhaled Antibiotics crease the rate of P. aeruginosa colonization in chil-
As noted previously, the airways of patients with CF dren with CF compared to culture-directed therapy
are often chronically infected with bacteria. The (34, 36).
most common bacterium found in the airways of When used to treat chronic P. aeruginosa infec-
patients with CF is P. aeruginosa (Fig. 14-2). It is tion, inhaled tobramycin and aztreonam are typi-
well known that the presence of P. aeruginosa is as- cally administered in 28-day on/off cycles. This
sociated with a more rapid decline in lung function approach is thought to minimize the development of
and increased mortality (7). This observation has led antibiotic resistance. However, patients with more
to aggressive approaches to eradicate this organism severe lung disease often alternate two antibiotics in
when it is first recovered (33). Inhaled antibiotics are monthly cycles so that they are always receiving an
a foundation of these eradication strategies. Once inhaled antibiotic. Although inhaled antibiotics are
the P. aeruginosa infection is established, patients an effective therapy, they do have unintended con-
often begin chronic inhaled antibiotic therapy to sequences. The marked increase in the prevalence
minimize the inflammation from the infection. The of fungi recovered from the airways of patients with
use of chronic inhaled antibiotic therapy for suppres- CF is due in part to the widespread use of inhaled
sion is associated with improved lung function and antibiotics (37).
fewer exacerbations (30).
Tobramycin and aztreonam are two inhaled
antibiotics approved by the U.S. Food and Drug ■ ■ Because he is not yet able to produce sputum,
Administration (FDA) for use in patients with CF. Ryan has a throat culture performed at each clinic
Although not FDA approved for inhalational use, visit to monitor his airway microbiology. His most
colistin (colistimethate sodium) has been used for recent culture has grown Pseudomonas aeruginosa.
many years as treatment for P. aeruginosa. The ra- Therefore, 1 month of inhaled tobramycin is pre-
tionale for the use of inhaled antibiotics is that they scribed as “eradication therapy.”
deliver a high concentration of drug to the airway
surface, where it is most needed, while minimizing
systemic drug toxicity. Other Inhaled Therapies
Mechanism of action Inhaled steroids are an attractive therapy to treat the
• Tobramycin: an aminoglycoside antibiotic that inflammation associated with CF lung disease. How-
blocks bacterial protein synthesis. ever, there is not enough evidence to recommend this
• Aztreonam: a monobactam antibiotic that in- therapy (26). Inhaled steroids can be considered in
hibits bacterial cell wall formation. patients who wheeze frequently. The same can be
2831_Ch14_355-380 13/03/14 3:31 PM Page 371
and survival. Ivacaftor is the first such therapy ap- findings, the CF Foundation strongly recommends
proved by the FDA. It is a small-molecule potentia- cleaning and disinfecting nebulizer equipment after
tor that activates defective CFTR at the cell surface each and every treatment (39).
that has been shown to improve sweat chloride, lung The first step in cleaning any respiratory device
function, weight, and quality of life (38). Ivacaftor is to remove secretions with soap and water. For
activates mutated CFTR in which glycine has been cleaning, fill a clean basin with warm, soapy water
replaced by aspartic acid at position 551 (G551D). and agitate the equipment pieces in it, removing any
If started early in the course of the disease, this ther- debris. Rinse with sterile water and then follow with
apy has the potential to alter the progression of an appropriate disinfection technique for the device
CF lung disease for patients with CF as a result of type (Table 14-5). Vinegar is not strong enough to
at least one G551D mutation. Therapies directed kill P. aeruginosa and is therefore not recommended
toward other defective forms of CFTR are currently for disinfecting respiratory equipment.
under way.
Adherence to Therapy
Infection Control Improved survival for patients with CF is thanks to
An important consideration for people with CF is in- the introduction of an aggressive approach to treat-
fection control (39). Health-care providers must take ment of airway obstruction and infection. A typical
precautions to avoid transmitting pathogens from therapeutic routine for many patients includes airway
one patient to another in both inpatient and outpa- clearance twice daily, mucolytic therapy, and inhaled
tient settings. Many of the bacteria colonizing the air- antibiotics. This regimen can take more than 1 hour
ways of children with CF are transmissible to others to administer twice daily. For this reason, CF therapy
with the disease. Therefore, it is of vital importance can be quite burdensome for patients and their
that excellent hand hygiene is practiced. Additional families. Adherence to prescribed therapies is vitally
precautions are warranted when individuals are col- important, and the role of the respiratory therapist
onized with certain bacteria such as B. cepacia. Many in encouraging adherence is key to the success of
CF centers see young patients with CF in clinics sep- therapy. Studies have shown that children and adults
arate from individuals colonized with P. aeruginosa, with CF who have better adherence have a slower de-
B. cepacia, MRSA, and other pathogens to prevent cline in lung function and fewer exacerbations (41).
early colonization. There are different challenges to adherence at
Although infection control in the health-care set- every age. Adherence to therapy tends to become
ting is important, most patients acquire colonizing worse in adolescence and early adulthood as patients
organisms from their everyday environmental expo- gain independence from their parents (41). Care-
sure, not from CF clinic visits (40). Infection control givers should strive to create an individualized care
must become a part of the family’s everyday life, es- plan that the patient can realistically complete on a
pecially in the care of their respiratory equipment. daily basis (Box 14-3). Instilling an understanding of
Studies have found that many pathogens remain on the rationale and importance of therapies will im-
respiratory equipment after use. Because of these prove adherence in the long run.
3 Brand names include Avent Iq24 and Nuk. These are available in the baby supply section of many department stores.
4 Brand names include Medela, Dr. Brown’s, and Munchkin. These are available in the baby supply section of many
department stores.
5For eFlow devices, the aerosol head should always be kept in isopropyl alcohol when not in use. eFlow devices have
Box 14-3 A Day in the Life of a Teenager More severe exacerbations are treated with
with CF intravenous (IV) antibiotics. Generally, pa-
tients who require IV antibiotics are admitted to
Morning the hospital for at least some portion of their ther-
apy. In addition to IV antibiotics, patients should
5:00 a.m. Wake up
receive more intensive airway clearance and aggres-
5:30 a.m. Morning Therapies
sive nutritional support during the hospital stay
Albuterol (5 min)
(38). From a respiratory standpoint, treatment will
Hypertonic saline (15 to 20 min)
vary from patient to patient. Options for inhaled
Airway clearance using
medications include the addition or increased fre-
HFCWO (30 min)
quency of albuterol, hypertonic saline, or dornase
Inhaled tobramycin (every
alfa. Airway clearance should be provided at least
other month) (15 to 20 min)
three to four times daily. There can be an important
6:30 a.m. Breakfast and off to school
role for bronchoscopy in exacerbation manage-
Evening ment. Bronchoscopy can be used therapeutically to
4:00 p.m. Homework treat mucus plugging and atelectasis or diagnosti-
6:00 p.m. Soccer Practice cally to obtain cultures from children who do not
7:00 p.m. Dinner expectorate sputum.
8:00 p.m. Evening Therapies The role of inhaled antibiotic therapy in patients
Albuterol (5 min) being treated with IV antibiotics is unclear. Inhaled
Dornase alfa (5 to 10 min) antibiotics deliver a high concentration of drug
Hypertonic saline (15 min) directly to the airway during illness, potentially lead-
Airway clearance using ing to better outcomes. However, there is also the po-
HFCWO (30 min) tential for increased toxicity when IV and inhaled
Inhaled tobramycin (every aminoglycoside antibiotics are administered together.
other month) (15 to 20 min) Unfortunately, there are no studies that clearly define
■ ■ Ryan is now 6 years old. He performs airway Box 14-4 Pulmonary Exacerbations
clearance twice daily and uses dornase alfa once
daily. He does typically cough on a daily basis, but Children with CF experience episodic increases in
does not produce sputum. P. aeruginosa has only respiratory symptoms known as pulmonary exac-
been cultured once, and it has not been found again erbations. These episodes can be acute or have an
after eradication therapy. insidious onset. Pulmonary exacerbations are
Over the past week Ryan has had an increased thought to be from an overgrowth of bacteria in
amount of coughing and is now producing sputum the airways of patients with CF in combination
on a daily basis. He has had one episode of post- with increased mucus production and inflamma-
tussive emesis. When he is examined in clinic he tion. Pulmonary exacerbations are characterized
has crackles on auscultation, and his FEV1 has by respiratory symptoms including the following:
fallen by 15%.
• Increased cough
• Increased sputum production
• Change in sputum color or composition
• Dyspnea
Pulmonary Exacerbation Therapy • Chest pain
Pulmonary exacerbations can be challenging for pa- • Weight loss
tients, families, and care providers (Box 14-4). These • Hemoptysis
episodes are characterized by increased airway secre- Exacerbations are rarely associated with fever.
tions, infection, and inflammation. Antibiotics are Physical examination can be deceptive. Although
the mainstay of exacerbation therapy. Antibiotics children experiencing a pulmonary exacerbation
can be administered either orally or via nebulizer to often have physical findings such as crackles on
treat mild exacerbations. Airway clearance should examination, patients can have a significant in-
also be increased to at least three to four times daily crease in symptoms and a fall in lung function yet
to mobilize secretions when children are ill. Addi- have a benign examination. Similarly, chest radi-
tional nebulized therapies, such as bronchodilators ographs may not show significant changes during
or mucolytics, can be employed to enhance airway an exacerbation.
clearance.
2831_Ch14_355-380 13/03/14 3:31 PM Page 374
an advantage or disadvantage of combined IV and Acute episodes of bleeding are typically associated
inhaled therapy (42). with infection. Therefore, treatment with antibiotics
The goal of exacerbation therapy is resolution of should be considered when hemoptysis occurs (45).
symptoms and improvement in lung function. The Evaluation of patients with significant hemoptysis
effectiveness of therapy can be monitored by im- should include hemoglobin count, platelet count, and
provement in symptoms, such as cough and sputum a prothrombin time to confirm whether the patient is
production, and physical findings, such as crackles. vitamin K deficient. Massive hemoptysis, defined as
If the chest radiograph does have significant changes, more than 250 mL of blood, can be life threatening.
then a follow-up radiograph should be obtained at The definitive treatment of recurrent or massive he-
the end of therapy. Typically, pulmonary function moptysis is bronchial artery embolization.
testing is the most important tool for monitoring the
success of therapy. Improvement in FEV1 can occur Pneumothorax
after just a few days of therapy and normally peaks About 3.4% of all patients with CF will experience
within 10 days of IV antibiotics (43). a pneumothorax in their lifetime (46). The annual
There are few randomized, controlled trials of incidence of pneumothorax in patients with CF is
exacerbation therapies, making it difficult to make approximately 1 in 167 patients (47). Pneumotho-
evidence-based recommendations for treatment. races typically present with pleuritic chest pain and
Unfortunately, up to one-third of patients do not dyspnea. Small pneumothoraces, without significant
recover their previous lung function despite aggres- cardiopulmonary compromise, can be treated con-
sive exacerbation therapy (44). Therefore, studies servatively with observation and analgesic therapy.
to determine the optimal approach to exacerbation Larger pneumothoraces require chest-tube drainage
therapy are needed. (45). Another optional treatment is pleurodesis,
which is the creation of adhesions between the two
thoracic pleura, to prevent recurrence of pneumoth-
■ ■ Based on Ryan’s clinical findings, he is diagnosed oraces. Careful consideration should be given be-
with a mild pulmonary exacerbation. You and the fore performing pleurodesis because the resulting
physical therapist also take this opportunity to re- adhesions may influence future transplant decisions.
assess Ryan and his family on their adherence to Pneumothorax has traditionally been considered to
prescribed maintenance therapy and techniques of be a poor prognostic indicator and to be a harbinger
airway clearance. They deny any problems with per- of a more rapid decline in lung function.
forming therapies and maintain that they consistently
adhere to the prescribed therapies. After observing Allergic Bronchopulmonary Aspergillosis
their techniques, you and the physical therapist Allergic bronchopulmonary aspergillosis (ABPA) is an
agree that Ryan’s exacerbations are not the result allergic reaction to a fungus commonly found in the
of poor adherence to therapy or technique. The environment (48). Allergy to Aspergillus fumigatus is
team recommends increasing his airway clearance the most common form of ABPA. The prevalence of
techniques to four times a day and coupling it with fungi in the airways of patients with CF has increased
a bronchodilator. The pulmonologist also prescribes 10-fold over the past decade to more than 30% in
Ryan a 28-day regimen of inhaled tobramycin and some centers (37). The symptoms of ABPA can over-
2 weeks of oral ciprofloxacin. lap those of CF, making the diagnosis difficult in
At a follow-up visit 1 month later, Ryan’s PFTs have some cases. The classic symptoms include wheezing,
returned to his baseline predicted values, and he is re- loss of lung function, and central bronchiectasis.
turned to his standard airway clearance regimen. Criteria have been developed for the diagnosis and
treatment of ABPA in patients with CF (48).
• A consensus conference convened by the CF
Complications Foundation has suggested minimal criteria
for the diagnosis of ABPA in patients with
Hemoptysis CF (48). These criteria include acute or suba-
Many patients with advanced lung disease will period- cute clinical deterioration (cough, wheeze, ex-
ically have hemoptysis, the expectoration of blood aris- ercise intolerance, exercise-induced asthma,
ing from the airway or lungs. Bleeding can range from change in pulmonary function, or increased
the expectorating blood-streaked sputum to frank sputum production) not attributable to an-
blood. Hemoptysis results from damage to fragile, tor- other etiology.
tuous bronchial arteries, which often form arteriove- • Total serum immunoglobulin E (IgE) concen-
nous fistulas with pulmonary vessels. Hemoptysis is tration greater than 500 IU/mL (1,200 ng/mL).
more common in patients with severe lung disease. If ABPA is suspected, and the total IgE level is
2831_Ch14_355-380 13/03/14 3:31 PM Page 375
this is a complicated and imprecise number, and it is Children with CF can look forward to novel ther-
not useful in predicting a particular person’s chances apies that will treat the basic defect in chloride trans-
of living to a particular age. There are many reasons port and revolutionize the approach to CF care.
for this increase in survival. Stronger partnerships Eventually, these disease-modifying therapies will
among people with CF, their families, and CF care be available for administration to infants with CF
center staff are key. Earlier diagnosis because of na- diagnosed by newborn screening, thereby preventing
tionwide newborn screening also plays a critical role. or greatly slowing the appearance of the manifesta-
The earlier CF is diagnosed, the sooner treatment tions of CF lung disease. However, none of these
can begin. therapies will reverse parenchymal lung disease.
Despite these promising numbers, 85% of patients Therefore, maintaining an aggressive approach to
with CF die from complications of their lung disease respiratory care and encouraging adherence to the
(2). Monitoring lung disease progression is a critical currently available therapies is vitally important.
role for health-care providers because it will help pa-
tients and their families make timely and informed
decisions about care. ■ ■ Ryan is now in 10th grade and using many
Progression of Lung Disease therapies to maximize his lung function. It can be an
arduous routine to maintain day in and day out, but
Airway obstruction, infection, and inflammation Ryan and his parents are committed to maintaining
leads to progressive damage to the CF lung. The his lung health. He is one of your most pleasant pa-
progression of respiratory disease varies and cannot tients, and you often look forward to talking with him
be predicted for individual patients by either the at each of his quarterly visits. He used twice-a-day
sweat chloride level or genotype. This uncertainty airway clearance using HFCWO, as well as albuterol,
can be frustrating for families and can create a great hypertonic saline, dornase alfa, and tobramycin
deal of stress. In general, patients who are pancreatic (every other month). He is active in soccer and loves
sufficient tend to have a slower progression of lung to watch scary movies. He is a math tutor for ele-
disease (54). Several factors have been shown to mentary school students and helps maintain the
negatively influence the progression of lung disease, website for his graduating class. He has been hospi-
including the following: talized twice in the last 5 years for pulmonary exac-
• Infection with P. aeruginosa (7, 54), B. cepacia erbations, each in the winter months and associated
(55), or MRSA (8, 56) with upper respiratory infections. In each case he
• Female gender (57, 58) was discharged within 4 days and never admitted to
• Diabetes ( 54,58) the intensive care unit. He confides to you that the
• Poor nutritional status (11, 54) most challenging part of trying to be a “normal kid” is
• Low socioeconomic status (57) when the clinic team increases his treatment regi-
• Lack of insurance (59) men to four times a day during mild pulmonary exac-
• Exposure to secondhand smoke (60) erbations. At those times he’s forced to spend his
• Presence of polymorphisms in modifier genes lunchtime in the school nurse’s office and has to go
such as transforming growth factor-beta home immediately after school to maintain treatment
(TGF-β) (61) and mannose binding lectin (62) compliance. Based on his PFTs, which remain within
90% of predicted values, his current treatment
Pulmonary function tests (PFTs) are the primary modalities seem to be effective.
mode of following disease progression in patients
with CF. The FEV1 is the test that has traditionally
been thought to best relate to mortality in patients
with CF (12). However, it is clear that the rate of de-
cline in lung function clearly influences morbidity ■■ Critical Thinking Questions: Ryan Greb
and mortality (63). 1. If Ryan had presented with more severe pulmonary
Although CF is a multisystem disease, mortality symptoms in infancy, what would be an effective
is due almost exclusively to lung disease. Therefore, way for his family to provide airway clearance
it is of vital importance to preserve lung function to techniques?
enhance survival. The consistent use of airway clear- 2. What clues would let you or the physical therapist
ance and inhalational therapies has the potential to know that Ryan or his parents were not being
continue to improve the lives of children with CF. compliant with his prescribed treatment regimen?
Patients, families, and caregivers must adopt a uni- 3. What role does infection play in the progression of
fied approach designed to prevent permanent lung Ryan’s CF lung disease?
damage.
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Multiple-Choice Questions
1. Which of the following are manifestations family nearby. What would you recommend as
typical in a school-aged child with CF? his therapy?
I. Productive cough a. Percussion and vibration, dornase alfa,
II. Wheeze albuterol SVN, and tobramycin four times
III. Meconium ileus a day
IV. Oily stools b. HFCWO, albuterol MDI, dornase alfa,
V. Nasal polyps and Colistin before school and after soccer
a. I, III, IV practice
b. I, II, III, IV, V c. HFCWO, albuterol SVN, and
c. I, III, IV, V N-acetylcysteine before and after school
d. I, II, IV d. Oscillating PEP, albuterol MDI, dornase alfa,
2. What test is the “gold standard” for diagnosing and hypertonic saline before school, during
CF? lunch break, and after soccer practice
a. Newborn screening 7. A 9-year-old patient, Jason, had a change to
b. Sweat test his new daily regimen of CF therapies. His
c. Nasal potential difference (NPD) test mom has called you because she lost the paper
d. Genetic testing for CTFR gene mutations that describes the correct order of therapies,
3. What is the best method for airway clearance but she still has the list of medications and
in a 3-year-old child without a history of GER? other therapies. Put in them in the order in
I. Percussion and vibration which they should be done.
II. HFCWO I. Albuterol (MDI)
III. ACB II. Tobramycin
IV. FET III. Pulmozyme
V. Oscillating PEP IV. HFCWO
a. I, II, III a. I, II, III, IV
b. I b. I, II, IV, III
c. I, II c. IV, I, II, III
d. I, II, III, V d. I,III,IV, II
4. Which nebulizer should be used to deliver 8. Identify common organisms that contribute to
tobramycin to a 13-year-old with CF? pulmonary exacerbations.
a. Small-volume nebulizer a. Aspergillosis fumigatus
b. PARI LC Plus b. Streptococcus pneumonia
c. Breath-actuated nebulizer c. Pseudomonas aeruginosa
d. Altera nebulizer d. Staphylococcus aureus
5. Which ACT can help improve FRC as well as 9. Which of the following complications is an
promote clearance of mucus? adult patient with CF most likely to have had
a. HFCWO at some point in his or her life?
b. Percussion, vibration, and postural a. Pneumothorax
drainage b. CF-related diabetes
c. PEP c. Allergic bronchopulmonary aspergillosis
d. ACB and FET d. Liver failure
6. You are asked to participate in prescription 10. Which of the following is not a strategy that
of pulmonary therapies for a 12-year-old who should be employed during any pulmonary
just moved to the area from another state and exacerbation?
is new to the clinic. He has not yet had a pul- a. Addition of or increased frequency of
monary exacerbation, is active in soccer and bronchodilator
baseball, and plays the trumpet in the middle b. Increase in frequency of ACTs
school band. His parents both work full time, c. bronchoscopy
and he is an only child. There is no other d. Antibiotic therapy
41. Eakin MN, Bilderback A, Boyle MP, Mogayzel PJ, Riekert 53. Benden C, Aurora P, Edwards LB, et al. The Registry of
KA. Longitudinal association between medication adher- the International Society for Heart and Lung Transplanta-
ence and lung health in people with cystic fibrosis. J Cyst tion: Fourteenth Pediatric Lung and Heart-Lung Trans-
Fibros. 2011;10(4):258-264. plantation Report—2011. J Heart Lung Transplant. 2011;
42. Flume PA, Mogayzel PJ, Jr., Robinson KA, et al. Cystic 30(10):1123-1132.
fibrosis pulmonary guidelines: treatment of pulmonary 54. Konstan MW, Morgan WJ, Butler SM, et al. Risk factors
exacerbations. Am J Respir Crit Care Med. 2009;180(9): for rate of decline in forced expiratory volume in one
802-808. second in children and adolescents with cystic fibrosis.
43. Collaco JM, Green DM, Cutting GR, Naughton KM, J Pediatr. 2007;151(2):134-139, 9 e1.
Mogayzel PJ, Jr. Location and duration of treatment of 55. Courtney JM, Dunbar KE, McDowell A, et al. Clinical
cystic fibrosis respiratory exacerbations do not affect out- outcome of Burkholderia cepacia complex infection in
comes. Am J Respir Crit Care Med. 2010;182(9):1137-1143. cystic fibrosis adults. J Cyst Fibros. 2004;3(2):93-98.
44. Sanders DB, Bittner RC, Rosenfeld M, Hoffman LR, 56. Dasenbrook EC, Merlo CA, Diener-West M, Lechtzin N,
Redding GJ, Goss CH, et al. Failure to recover to baseline Boyle MP. Persistent methicillin-resistant Staphylococcus
pulmonary function after cystic fibrosis pulmonary exacer- aureus and rate of FEV1 decline in cystic fibrosis. Am J
bation. Am J Respir Crit Care Med. 2010;182(5):627-632. Respir Crit Care Med. 2008;178(8):814-821.
45. Flume PA, Mogayzel PJ, Jr., Robinson KA, Rosenblatt 57. Barr HL, Britton J, Smyth AR, Fogarty AW. Association
RL, Quittell L, Marshall BC, et al. Cystic fibrosis pul- between socioeconomic status, sex, and age at death from
monary guidelines: pulmonary complications: hemoptysis cystic fibrosis in England and Wales (1959 to 2008): cross
and pneumothorax. Am J Respir Crit Care Med. 2010; sectional study. BMJ. 2011;343:d4662.
182(3):298-306. 58. Chamnan P, Shine BS, Haworth CS, Bilton D, Adler AI.
46. Flume PA. Pneumothorax in cystic fibrosis. Curr Opin Diabetes as a determinant of mortality in cystic fibrosis.
Pulm Med. 2011;17(4):220-225. Diabetes Care. 2010;33(2):311-316.
47. Flume PA, Strange C, Ye X, Ebeling M, Hulsey T, Clark 59. Curtis JR, Burke W, Kassner AW, Aitken ML. Absence
LL, et al. Pneumothorax in cystic fibrosis. Chest. 2005; of health insurance is associated with decreased life ex-
128(2):720-728. pectancy in patients with cystic fibrosis. Am J Respir Crit
48. Stevens DA, Moss RB, Kurup VP, et al. Allergic bron- Care Med. 1997;155(6):1921-1924.
chopulmonary aspergillosis in cystic fibrosis-state of the 60. Collaco JM, Vanscoy L, Bremer L, et al. Interactions be-
art: Cystic Fibrosis Foundation Consensus Conference. tween secondhand smoke and genes that affect cystic fibro-
Clin Infect Dis. 2003;37(suppl 3):S225-S264. sis lung disease. JAMA. 2008;299(4):417-424.
49. Lebecque P, Leonard A, Pilette C. Omalizumab for treat- 61. Drumm ML, Konstan MW, Schluchter MD, et al. Genetic
ment of ABPA exacerbations in CF patients. Pediatr modifiers of lung disease in cystic fibrosis. N Engl J Med.
Pulmonol. 2009;44(5):516. 2005;353(14):1443-1453.
50. Moran A, Brunzell C, Cohen RC, et al. Clinical care 62. Buranawuti K, Boyle MP, Cheng S, et al. Variants in
guidelines for cystic fibrosis-related diabetes: a position mannose-binding lectin and tumour necrosis factor alpha
statement of the American Diabetes Association and a affect survival in cystic fibrosis. J Med Genet. 2007;44(3):
clinical practice guideline of the Cystic Fibrosis Founda- 209-214.
tion, endorsed by the Pediatric Endocrine Society. 63. Corey M, Edwards L, Levison H, Knowles M. Longitudinal
Diabetes Care. 2010;33(12):2697-2708. analysis of pulmonary function decline in patients with cys-
51. Riekert KA, Bartlett SJ, Boyle MP, Krishnan JA, Rand tic fibrosis. J Pediatr. 1997;131(6):809-814.
CS. The association between depression, lung function, 64. Kraynack NC, Gothard MD, Falletta LM, McBride JT.
and health-related quality of life among adults with cystic Approach to treating cystic fibrosis pulmonary exacerba-
fibrosis. Chest. 2007;132(1):231-237. tions varies widely across US CF care centers. Pediatr
52. Efrati O, Bylin I, Segal E, et al. Outcome of patients with Pulmonol. 2011;46(9):870-881.
cystic fibrosis admitted to the intensive care unit: is inva- 65. Konstan MW, Schluchter MD, Xue W, Davis PB. Clinical
sive mechanical ventilation a risk factor for death in use of ibuprofen is associated with slower FEV1 decline in
patients waiting lung transplantation? Heart Lung. 2010; children with cystic fibrosis. Am J Respir Crit Care Med.
39(2):153-159. 2007;176(11):1084-1089.
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Chapter 15
Pediatric Pulmonary
Diseases Vinay Nadkarni, MD
Roberta Hales, MHA, RRT-NPS, RN
Shawn Colbourn, AS, RRT-NPS
381
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Chapter Objectives
After reading this chapter, you will be able to:
1. Assess the need for hospital admission for a pediatric patient with signs of respiratory distress.
2. Identify the signs and symptoms used when classifying bronchiolitis severity.
3. Select an oxygen-delivery device for a patient with bronchiolitis or pneumonia based on age, required
concentration of inspired oxygen, and severity of respiratory distress.
4. List the different pathogens responsible for pediatric pneumonia.
5. Assess the effectiveness of noninvasive ventilation in managing a patient with hypoxemia and alveolar
instability associated with pneumonia.
6. Describe the four clinical characteristics of acute respiratory distress syndrome (ARDS).
7. Describe the chest radiograph findings for bronchiolitis, pneumonia, and ARDS.
8. Describe the benefits of advanced modes of ventilation in improving gas exchange in ARDS.
9. Recommend ventilator setting changes for a patient on airway pressure release ventilation with ARDS
and respiratory acidosis.
R
espiratory disorders account for 27.8% of
associated with bronchiolitis is apnea, particularly
all pediatric hospital admissions through
in the premature, low birth weight, or young infant
the ED, and acute respiratory distress is the
(less than 3 months of age). The natural history
most common cause of illness requiring hospital-
of the disease is that severity worsens over the first
ization in infants and children less than 15 years of
72 hours, then plateaus for a few days and resolves
age (1). These children usually require acute man-
over several weeks. Risk factors for more severe
agement and frequent assessment of respiratory
symptoms include the following:
distress, and a small percentage will need intensive
care management to prevent respiratory failure • Young age, that is, infants younger than
and circulatory collapse. With even mild respira- 3 months old
tory impairment, most of these children will require • Low birth weight
at least one type of respiratory therapy, which • Premature birth less than or equal to 36 weeks
could include airway clearance, supplemental oxy- • Congenital heart disease
gen therapy, deep breathing exercises, chest phys- • Chronic lung disease
iotherapy, and inhaled medications. More severe • Airway abnormalities (e.g., bronchomalacia)
cases will require noninvasive ventilation, specialty • Neurological abnormalities with dystonia
2831_Ch15_381-414 13/03/14 3:27 PM Page 383
Physical assessment focuses on classifying the Apnea may be attributed to a mix of both central and
severity of respiratory distress and hydration and obstructive apnea. It rarely lasts more than a few
thus the severity of the disease. Clinical signs and days, and fewer than 10% of patients who present
symptoms of bronchiolitis include the following: with an episode of apnea require intubation and
ventilation (5, 6).
• Low-grade fever
• Rhinorrhea Diagnostic Testing
• Cough
The most common diagnostic testing used for acute
• Tachypnea, earliest sign of change in status of
bronchiolitis includes viral detection and chest radi-
disease
ographs. The American Academy of Pediatrics (AAP)
• Tachycardia
guidelines (14) do not support the use of these tests in
• Retractions, subcostal and intercostal
the management of routine cases; however, they are
• Nasal flaring
still commonly prescribed clinically to assist in diag-
• Expiratory wheezing, with or without bilateral
nosis of bronchiolitis.
crackles
• Prolonged expiratory time RSV Testing
• Cyanosis
RSV viral antigen testing has variable sensitivity
Respiratory rate, WOB, and hypoxemia are the and specificity, and it is generally good at detecting
most clinically significant patient-assessment param- viruses during the peak viral season. Even so, viral
eters used to determine the severity of illness, and sev- pathophysiology is usually equivalent. The iden-
eral patient-assessment tools have been designed to tification of the specific virus has little to no im-
objectively measure respiratory distress (11-13) pact on clinical management or outcome of the
(Table 15-1, Table 15-2). The most significant conse- disease. However, the identification of a specific
quence of bronchiolitis is hypoxemia. Hypoxemia virus on the hospitalized patient may assist the
results from a V/Q mismatch at the alveolar health-care provider in preventing and reducing
capillary membrane. Specifically, this mis- the spread of hospital-acquired infections or allow
match occurs because there are alveoli being perfused discontinuation of antibiotics or other medication
but not ventilated owing to the collapse of small air- exposures.
ways (bronchioles) and microatelectasis. Hypercar-
bia can occur because of an increase in the dead Chest Radiographs
space-to-tidal volume (VT) ratio, thus decreasing Chest radiographs are an important diagnostic tool
the amount of functional lung participating in gas used in the diagnosis of respiratory distress. In
exchange. Careful monitoring is necessary to detect acute bronchiolitis, radiographs may reveal areas
periodic breathing, central apnea, and cardiopul- of overinflation along with patchy infiltrates attrib-
monary instability in the young and premature infant. uted to atelectasis. However, the AAP does not
Wheezing
During expiration None End 1/2 3/4 All 4
During inspiration None Part All 2
Number of involved None Segmental Diffuse 2
lung fields
Retractions
Supraclavicular None Mild Moderate Marked 3
Intercostal None Mild Moderate Marked 3
Subcostal None Mild Moderate Marked 3
Total 17
The total score on the RDAI is the sum of the scores for each row, with a range of 0 to 17; higher scores indicate more
severe respiratory distress.
2831_Ch15_381-414 13/03/14 3:27 PM Page 385
of clinical outcomes (9). For these reasons, the secretions. If higher negative pressure is used, the
AAP has issued evidence-based clinical guidelines health-care provider should provide intermittent
focusing on the diagnosis, management, and preven- suction to minimize nasal trauma.
tion of bronchiolitis in children up to the age of
2 years (14). These guidelines are not intended to Oxygen Therapy
be a substitute for clinical expertise; they are a re- The delivery of supplemental oxygen therapy is the
source for the health-care provider in the manage- cornerstone for treatment and prevention of hypox-
ment of acute bronchiolitis. Respiratory care for emia. Oxygen therapy is initiated to maintain a
bronchiolitis should be focused on secretion clear- minimum level of SpO2 at 94%; however, AAP rec-
ance, frequent monitoring of respiratory status, ommends initiating oxygen below an SpO2 of 90%
and escalation of oxygen and ventilatory support because it is an acceptable point on the oxyhemo-
as needed by the patient. This section will review globin dissociation curve (9, 14). It is important to
all of the current treatments commonly in use for remember that at the peak of illness a higher level
RSV and will address the amount of evidence behind of supplemental oxygen may be needed because
their use, as well as whether they are currently part several factors may shift the oxyhemoglobin disso-
of the AAP’s recommendations for bronchiolitis ciation curve, such as fever, acidosis, and hemoglo-
management. binopathies. These shifts cause large decreases in
the partial pressure of oxygen (PaO2) to occur at a
Suctioning and Mucus Clearance SpO2 greater than 90% (17, 18) (Fig. 15-1). Supple-
In acute bronchiolitis, nasal obstruction is the most mental oxygen should be titrated based on the com-
common problem in young infants. Because infants plete physical examination because a low oxygen
are classified as obligate nose breathers (Special saturation level measured using pulse oximetry is
Population 15-1), nasal congestion and blockage an influential parameter in determining the need for
can range from a mild nuisance to a life-threatening hospital admission. However, the use of continuous
respiratory distress. Nasal suctioning and saline pulse oximetry monitoring during an in-patient
drops might help alleviate the nasal congestion, but admission may also contribute to a prolonged hos-
there is no clear evidence to determine whether it is pital course. For this reason, pulse oximetry meas-
effective in the overall clinical management. In ad- urements should be confirmed for accuracy prior
dition, there is no evidence to support deep suction- to initiating supplemental oxygen and limited to
ing of the pharynx or lower pharynx. Nevertheless, severely ill patients. If the SpO2 consistently meas-
infants may require frequent nasal suctioning to ures below 90% and the infant or child exhibits
clear their nasal passages. Frequent suctioning has signs of respiratory distress, then supplemental
some risks, including inflammation, bleeding, and oxygen is necessary. The selection of an oxygen-
trauma to the nasal mucosa. Therefore, the selection delivery device depends on the age and size of
of the suction device should be geared toward max- the child, patient tolerance, and humidification.
imum effectiveness with minimal trauma and lim- (Table 15-3 describes recommended delivery de-
ited to patients with an SpO2 less than 90% and/or vices.) Oxygen should be discontinued if the infant
moderate-to-severe respiratory distress. or child is able to maintain a SpO2 greater than 90%
The preferred suctioning method uses an acorn
nasal aspirator or bulb suction because of the mini-
mal negative pressure; however, in the hospital a suc- Left shifted (increased affinity)
100
Temp
tion catheter with a side-control port can be used to
2-3 DPG
nasally suction the patient. At times, a higher nega- [H⫹]
tive pressure may be needed to remove the copious 80
CO
Right shifted
(reduced affinity)
● Special Populations 15-1 60
SO2 (%)
Temp
2-3 DPG
Obligate Nose Breathers [H⫹]
40
Infants prefer to breathe through the nasal passages
because of the physical structure of the upper air-
way. The soft palate is in direct contact with the 20
epiglottis, and the tongue fills most of the oral cavity.
These physical structures make it difficult for the
infant to effectively breathe through the oral cavity. 0
0 20 40 60 80 100 120
However, most infants can breathe through their
PO2
mouths if the nasal passages are blocked.
Figure 15-1 Oxyhemoglobin Dissociation Curve
2831_Ch15_381-414 13/03/14 3:27 PM Page 387
while resting and/or feeding with minimal respira- per minute [LPM] pediatric cartridge and 8 to
tory distress. 40 LPM adult cartridge) to be tolerated by patients
(19). These flow rates should exceed the patient’s in-
High-Flow Nasal Cannula spiratory flow demand at various minute volumes,
One of the newest high-flow oxygen-delivery systems eliminating the entrainment of room air. To further
being used in patients with impending respiratory guarantee FIO2 delivery, the HFNC uses an oxygen/
failure is the high-flow nasal cannula (HFNC), air blender as the main driving gas source. Addi-
which provides high-flow gas heated with nearly tionally, the HFNC uses the nasal pharynx as the
100% humidity, allowing higher flows (1 to 8 liters gas reservoir, reducing the anatomical dead space
2831_Ch15_381-414 13/03/14 3:27 PM Page 388
(upper airway) by flushing the end expiratory gas Table 15-4 Helium Oxygen Ratio Correction
from the system. This flushing enhances CO2 clear- Factor for Oxygen Flowmeters (22)
ance and oxygenation, thus improving the patient’s
respiratory status. Heliox Helium-Oxygen Mixture
Table 15-5 Dosage and Routes for Albuterol and Racemic Epinephrine (26)
Medication Indication Concentration Dosage Route Frequency Diluent
and reduce WOB. The current recommendation on observed for changes in respiratory and feeding sta-
chest physiotherapy for acute bronchiolitis is in- tus. Patients in impending respiratory failure are at
conclusive (33), although it may be considered for risk for aspiration; thus, oral nutrition may need to
patients with severe plugging and atelectasis. be held or reduced to decrease the risk of aspiration.
If oral feeding becomes inadvisable because of severe
Patient Positioning respiratory distress, the infant or child should be
There is no clear evidence that certain body positions placed on intravenous fluids to rehydrate. If oral
will decrease respiratory distress. Infants and chil- feeding is delayed for more than 2 days, a nasogas-
dren should be allowed to position themselves in tric tube should be placed for enteral feeding to pro-
whatever way is comfortable for them. For infants vide nutritional support.
who cannot position themselves, side-lying or supine
positions may be used with the head slightly ele- Glucocorticoids
vated. If prone positioning is used, continuous pulse Systemic glucocorticoids have been intermit-
oximetry monitoring must be used because of the tently used for routine treatment of acute viral bron-
higher risk of sudden infant death syndrome (SIDS) chiolitis for the past 40 years. The rationale is that
(Special Population 15-2). the anti-inflammatory effects should help in the early
stages of bronchiolitis because acute inflammation
Fluid Management of the bronchioles is one of the primary components
All children with bronchiolitis need hydration and in the disease. However, the evidence shows no ben-
fluid status evaluation. They are very susceptible to efit in decreasing the in-patient length of stay or clin-
dehydration because of high insensible water loss, ical outcomes in infants and children treated with
elevated respiratory rate, fever, copious secretions, systemic glucocorticoids (34). Because the safety of
and poor feeding (9). In mild respiratory distress, high-dose inhaled corticosteroids for infants is not
the infant or child may continue to feed but must be yet known, the AAP recommends avoiding their use
in small children unless there is a clear likelihood of
benefit (14).
● Special Populations 15-2
Antibiotics
Sudden Infant Death Syndrome The risk for a bacterial infection with bronchiolitis is
SIDS is defined as the unexplained death of a healthy low, at less than 1% (35–38). Approximately 25% of
newborn. It typically occurs in infants 2 to 4 months hospitalized infants with bronchiolitis will have radi-
of age, with a range of 1 to 6 months of age. Risk ographic evidence of atelectasis or infiltrates, often
factors for SIDS include the following: misinterpreted as possible bacterial infection (39).
For that reason, antibiotic therapy is still used in the
• Male sex treatment of young infants. Antibiotic therapy is not
• Premature or low birth weight recommended for routine treatment of viral bronchi-
• African American, American Indian, or Native olitis, however, and should only be used if there is a
Alaskan suspicion and/or confirmation of a secondary bacte-
• Sleeping on the stomach rial infection.
• Being born to mothers who smoke or take drugs
• Exposure to secondhand tobacco smoke Ribavirin (Virazole)
• Overheated homes Ribavirin is a broad-spectrum antiviral med-
• Being born during fall or winter months ication used in the treatment of children with severe
• Upper respiratory infection RSV. Though it used to be a mainstay of treatment
• Being a sibling of a baby who died from SIDS for all patients with RSV bronchiolitis, it is no longer
Prevention factors include the following: recommended routinely for inpatients with bronchi-
• Placing baby on his or her back to sleep olitis. This is because of its marginal benefit, if any,
• Not smoking or exposing the baby to secondhand for most patients. It should, however, be considered
smoke for patients with severe disease or those who have
• Selecting appropriate bedding: firm mattress, significant underlying risk factors such as congenital
fitted sheets, and no lambskin, quilt, pillow, or immunodeficiency, organ and bone marrow trans-
stuffed animals (to prevent the risk of smothering) plants, and chronic lung and congenital heart dis-
• Caregivers not sleeping with the infant in their bed eases. Other considerations for not using ribavirin
• Maintaining a moderate room temperature include high cost and lack of demonstrated benefit
• Breastfeeding, which some research has linked to in decreasing hospitalization or mortality, in addi-
lower incidence of SIDS tion to the occupational health risk to health-care
providers.
2831_Ch15_381-414 13/03/14 3:27 PM Page 391
BiPAP is delivered via nasal mask, nasal prongs, or Health-care providers also should adhere to iso-
full-face mask, and similar care must be taken to lation precautions in the hospital. High-risk infants
protect the patient’s skin integrity. BiPAP should should have limited exposure to settings where trans-
be considered when the infant or child needs extra mission is common, such as day-care settings.
support for ventilation and/or oxygenation. Initial Palivizumab, a humanized monoclonal an-
bilevel settings include selecting a mode, an inspira- tibody vaccine, is indicated as a preventive
tory positive airway pressure (IPAP), an expiratory measure against RSV for select infants and children
positive airway pressure (EPAP), and FIO2. in high-risk groups younger than 24 months. Three
groups of children qualify for the vaccine:
A. Mode of ventilation
1. Spontaneous (pressure support): Patient’s 1. Infants born before 35 weeks of gestation
spontaneous inspiratory effort triggers the 2. Infants with chronic lung disease
ventilator to deliver IPAP. 3. Infants born with hemodynamically signifi-
2. Spontaneous timed (pressure support with cant congenital heart disease (40)
backup rate): Patient’s spontaneous inspira-
Palivizumab has been shown to reduce hospital-
tory effort triggers the ventilator to deliver
izations in premature infants and children younger
IPAP. If the patient’s spontaneous respira-
than 2 years with hemodynamically significant car-
tory rate decreases below the preset rate, the
diac disease; however, no studies have yet demon-
ventilator triggers a pressure control breath
strated reduced mortality (6). Additionally, it appears
according to the preset IPAP level.
the medication is less effective in infants and children
B. IPAP initial setting: 8 to 10 cm H2O. Effectiveness with comorbidities, such as very premature infants
of IPAP setting should be assessed by evaluating with chronic lung disease (41).
the following and changing settings as needed: Additional preventive strategies include the
1. Good chest wall excursion with resolution following:
of tachypnea and hypercapnia
• Avoiding tobacco smoke, which is an inde-
2. Increase IPAP by 2 cm H2O if there is per-
pendent risk factor in bronchiolitis (42–44)
sistent hypercapnia
• Breastfeeding, owing to the fact that human
3. Increase IPAP by 2 cm H2O if there is per-
milk contains immune factors that decrease the
sistent hypoxemia
risk of acquiring viruses such as RSV because
4. Maximum IPAP varies based on patient size
it contains immunoglobulin G, immunoglobu-
but should be no higher than 20 cm H2O to
lin A, and alpha interferon (45).
avoid gastric distension
C. EPAP initial setting: 4 to 6 cm H2O
1. Patients with severe hypoxemia or air trap- ■ ■ After donning a gown, gloves, and a mask, you
ping may require higher levels of EPAP to support Jacob’s spontaneous respirations by provid-
increase mean airway pressure to improve ing blow-by oxygen and positioning him upright to
oxygenation and ventilation matching or to optimize air movement. These maneuvers increase
counter elevated levels of intrinsic positive- Jacob’s SpO2 above 95%.
end expiratory pressure. Increase EPAP by Once you’ve improved Jacob’s oxygen, the nurse
1 to 2 cm H2O pressure if hypoxemia is places an intravenous catheter and starts fluid ther-
persistent. apy at maintenance rate. You suggest a trial of in-
2. Maximum EPAP varies based on patient haled bronchodilator therapy for Jacob because of
size but should be no higher than 10 to the bilateral scattered wheezing heard on ausculta-
15 cm H2O. tion. You administer 1.25 mg albuterol sulfate via a
small-volume nebulizer with an aerosol mask. After
Predictors of success for BiPAP include a decrease the nebulizer, reassessment reveals no change in
in PaCO2, improvement in oxygenation, and correc- breath sounds or current respiratory status. You
tion of respiratory acidosis. Predictors of failure for suggest a trial of racemic epinephrine (0.25 mL of
BiPAP ventilation include persistent hypercapnia 2.5%) to capitalize on the alpha effect of the medica-
and acidosis and a decrease in level of consciousness. tion. There is minimal change in breath sounds,
but there may be a slight increase in air entry. The
Prevention patient care team discusses whether to repeat
Because viral infections are transmitted through direct the racemic epinephrine secondary to the slight
person-to-person contact or contact with fomites, fre- improvement in air entry. After much discussion,
quent hand hygiene is the first line of protection racemic epinephrine is not repeated. You note
against infectious viral pathogens. that the patient has copious nasal secretions and
2831_Ch15_381-414 13/03/14 3:27 PM Page 393
a consistently low SpO2 of less than 90%. You rec- • Smoking or secondhand smoke exposure
ommend nasal suctioning to help alleviate nasal ob- • Hospitalization in an intensive care unit (ICU)
struction. The physician and nurse agree. Together, • Chronic lung disease requiring long-term
you and the nurse suction the nasal passages at low inhaled corticosteroids
negative pressure to minimize nasal mucosal trauma. • Exposure to certain chemicals or pollutants
Jacob’s SpO2 increases to 92%, and he exhibits a (e.g., chlorine, inhaled pesticides, vomitus,
slight decrease in WOB. You help the nurse trans- smoke)
port Jacob to the infant care in-patient unit. • Indoor air pollution
• Living under crowded conditions
• Surgery or traumatic injury
• Ethnicity (Native Alaskans have a 60%
Course and Prognosis greater risk of contracting influenza and
Over the past several decades, a better understanding pneumonia) (51)
of the pathophysiology of viral infections has im- Pneumonia can be caused by bacteria, viruses,
proved outcomes for children hospitalized with acute fungi, protozoa, chemicals, foreign bodies, or irri-
bronchiolitis. Mortality rates are less than 1% (less tants. S. pneumoniae is the most common bacterial
than 500 deaths) per year in the United States (46) organism causing pneumonia in children (51).
but can be as high as 600,000 in other parts of the Other common bacterial causes include the
world (47). Most hospitalized infants recover from following:
acute bronchiolitis without sequelae within 3 to 4 days,
whereas high-risk infants are hospitalized longer with • Staphylococcus aureus
a higher rate of intensive care admission and mechan- • Streptococcus pyogenes (group A Streptococcus)
ical ventilation. One study found that approximately • Klebsiella pneumoniae
40% of survivors have subsequent wheezing episodes • Pseudomonas aeruginosa
up to the age of 5 years, and 10% have subsequent • Haemophilus influenzae
wheezing episodes after 5 years (48). It has also been • Chlamydia pneumoniae
suggested that RSV in infancy is an independent risk • Mycoplasma pneumoniae
factor for recurrent wheezing and asthma (6). Viruses more commonly cause pneumonia in
As future researchers investigate the propensity of younger populations (52). Although measles and
children with bronchiolitis to develop asthma, pres- RSV are the most common viruses causing pneumo-
ent clinical management should focus on preventive nia in children (51), other viral causes include the
measures along with research for developing a valid following:
and reliable severity scoring system that is sensitive
to important clinical changes in bronchiolitis. • Influenza
• Adenovirus
Pneumonia • Metapneumovirus
• Parainfluenza
Pneumonia is an inflammation of the lung tissue me- • Rhinovirus
diated by an immunological response to infectious
Other atypical causative agents include mycoplasm
agents. It is the leading cause of death in children
tuberculosis, fungal infections, and oral anaerobes.
worldwide, killing an estimated 1.6 million children
Pneumonia is often classified into the following
every year (49). In the United States, Streptococcus
four general categories:
pneumoniae is responsible for 100,000 to 135,000
hospitalizations in children younger than 5 years old • Aspiration pneumonia
each year (50). Although pneumonia is the leading • Community-acquired pneumonia
cause of death, it is preventable by immunization, • Hospital-acquired pneumonia
adequate nutrition, and addressing environmental • Immunocompromised (opportunistic)
factors. Additionally, it is a largely treatable disease pneumonia
with early and advanced treatment and supportive
Other types of pneumonia include severe acute
care. Factors associated with an increased risk of
respiratory syndrome, bronchiolitis obliterans or-
pneumonia include the following:
ganizing pneumonia, and eosinophilic pneumonia.
• Age (very young children with immature im- Each type of pneumonia is associated with an array
mune systems) of different pathogens and routes of transmission,
• Concomitant immune deficiency diseases which helps to dictate the type of “isolation” that
(e.g., leukemia) or chronic illnesses (e.g., chronic is necessary when caring for these patients. The
lung disease, congenital heart disease) most common routes of transmission are inhalation
2831_Ch15_381-414 13/03/14 3:28 PM Page 394
Normal
Older Temperature Temperature >38.5°C
Children <38.5°C RR >50 breaths/min
Foreign material
(bacteria,
RR <50 breaths/ Severe difficulty in
cellular debris) min breathing
Mucus Mild Nasal flaring
Thickened breathlessness Cyanosis
Abnormal alveolar walls
No vomiting Grunting respiration
Figure 15-2 Alveolar Capillary Membrane Impairment Signs of dehydration
During Pneumonia
2831_Ch15_381-414 13/03/14 3:28 PM Page 395
A
Diagnostic Testing
Diagnostic testing for pneumonia focuses on obtain-
ing a definitive diagnosis of pneumonia and deter-
mining the causative agent using sputum cultures,
bronchoalveolar lavage, and blood cultures, and
then assessing how much of the lung is affected,
using chest radiography.
Chest Radiographs
Chest radiographs are very helpful to confirm
the diagnosis of pneumonia; however, they can only
suggest but cannot confirm the underlying causative
agent. Viral and bacterial pneumonias are often sim- B
ilar in clinical presentation, but they present differ-
Figure 15-4 Comparison of Viral (A) and Bacterial
ently radiographically (Table 15-7). Classically, viral
(B) Pneumonias (Courtesy of Jane Benson, MD)
pneumonia presents as a diffuse interstitial or peri-
bronchial infiltrate, whereas bacterial pneumonia
presents as a lobar or alveolar consolidation (55) amount of pleural fluid is discovered, a thoracentesis
(Fig. 15-4). If pleural fluid is present, a lateral decu- should be performed, and fluid should be sent for
bitus radiograph can help differentiate between culture and sensitivity to determine the pathogen
a pleural effusion and empyema. If a significant and antibiotic regimen.
Viral Measles, RSV, influenza, Fluids, oxygen if needed, antivi- Diffuse interstitial or peribronchial
parainfluenza, adenovirus, ral medications, ibuprofen, infiltrates
metapneumovirus acetaminophen
Bacterial S. aureus, K. pneumoniae, Amoxicillin, Augmentin, penicillin, Lobar or alveolar consolidation
S. pyogenes, P. aerugi- clindamycin, erythromycin,
nosa, H. influenzae vancomycin, second-generation
cephalosporin
Atypical M. pneumoniae Erythromycin Patchy and segmental or nonseg-
mental with the presence of
airspace opacification
2831_Ch15_381-414 13/03/14 3:28 PM Page 396
Inhaled Antibiotics
Pentamidine isethionate is an antibiotic ad-
Clinical Variations 15-1 ministered with a nebulizer or intravenously for
P. jiroveci pneumonia (Box 15-1). There are impor-
Pneumocystis Jiroveci Pneumonia tant considerations when administering inhaled
antimicrobials. The most common method of ad-
Pneumocystis carinii pneumonia (PCP) infections were
ministration involves using two separate nebuliz-
renamed in 2002. It was found that PCP is a rat strain
ers: small volume and Respirgard II (Fig. 15-5).
of pneumonia that cannot infect humans, so the new
Aerosolized pentamidine has been documented
species was named Pneumocystis jiroveci pneumonia
as causing conjunctivitis and bronchospasm in
(PJP). It is named after Dr. Otto Jirovec, who discov-
health-care workers exposed to the drug during
ered the strain. It is still abbreviated PCP, however,
treatments (59). As a result, the patient must be
not PJP.
capable of using a mouthpiece so that the health-care
PCP is caused by the fungus P. jiroveci. This fun-
provider’s exposure to pentamidine is limited. For
gus is common in the environment and does not
added protection, the health-care provider should
cause illness in healthy people. PCP is relatively
wear an N95 mask to prevent inhalation of the an-
rare in people with normal immune systems, but it
tibiotic. An N95 mask is a specialized face mask that
is common among people with weakened immune
protects against 95% of respirable particles.
systems, such as premature or severely malnour-
ished children, the elderly, and especially individuals Suctioning and Mucous Clearance
living with HIV/AIDS, in whom it is most commonly
observed. PCP can also develop in patients who The goal of secretion clearance therapy is to mobi-
are taking immunosuppressive medications. lize and expel mucus in the respiratory tract. Cur-
rent secretion-clearance techniques include postural
2831_Ch15_381-414 13/03/14 3:28 PM Page 398
Box 15-1 Pentamidine Isethionate drainage, percussion and vibration; suctioning, po-
Procedure sition changes, high frequency chest wall oscillation;
forced expiratory technique; positive expiratory
• A negative flow room or laminar flow hood is pressure (PEP) and oscillating PEP devices; and
recommended. intrapulmonary percussive ventilation (60, 61). A de-
• Examine the prepared solution of pentamidine scription of each can be found in Chapter 14. However,
isethionate for cloudiness. If cloudy, return it current evidence is lacking regarding the effective-
to the pharmacy for another dose. ness of these techniques. Poor fluid hydration may
• Use universal precautions, including a particu- lead to inspissated mucus, which hinders adequate
late respiratory mask. secretion clearance. This is another reason for ade-
• Perform basic physical assessment (HR, quate hydration and fluid maintenance.
breath sounds, breathing pattern and fre- Glucocorticoids
quency, SpO2, and determination of cogni-
tive ability). There is some clinical evidence that corticosteroids
• Administer a bronchodilator in a small- can shorten the length of hospitalization and side
volume nebulizer. effects such as sepsis, septic shock, and bacterial
• Coat the mouthpiece of the pentamidine meningitis in adults and children (62). It can clearly
isethionate nebulizer with fruit flavors, reduce pulmonary inflammation. One small study of
or the patient may suck on hard candy children with severe community-acquired pneumonia
to cope with the metallic taste of the showed a mild improvement in outcomes with an
medication. early, low-dose, and short-term systemic corticos-
• Administer pentamidine isethionate with the teroid regimen paired with antimicrobial therapy (62).
Respirgard II Nebulizer (Figure 15-6). However, there is not significant evidence that routine
• Terminate nebulizer flow prior to removal use of steroids improves outcomes for pneumonia in
from the patient’s mouth. either children or adults. Because of their immuno-
• Reassess the patient intermittently and suppressive and other negative effects (discussed in
at the conclusion of therapy (HR, breath Chapter 13), steroids are not routinely recommended.
sounds, breathing pattern and frequency, They may be used for patients with a medical history
SpO2, and determination of cognitive of severe wheezing or an active component of reactive
ability). air disease (5).
• Discard the nebulizer and other disposable Mechanical Ventilation
items.
All patients with pneumonia, regardless of
causative agent, are at risk for respiratory failure.
Only a small fraction (17%) of children admitted to
the ICU in the United States will require assisted
mechanical ventilation (63). Mechanical ventilation
One way valves Filter can be administered noninvasively or invasively.
NIPPV may be attempted for patients in impending
respiratory failure to reduce the severity of respira-
tory distress and improve oxygenation and ventila-
tion. Invasive mechanical ventilation is reserved for
patients in acute respiratory failure or failure of a
trial of NIPPV. Endotracheal intubation should be
Gas flow performed for continued respiratory distress with
increasing hypercarbia, acidosis, and hypoxemia.
The patient should also be placed on continuous
monitoring that consists of cardiorespiratory, pulse
oximetry, and capnography. Initial ventilator set-
tings by age can be found in Table 15-8.
Course and Prognosis
In most cases of childhood pneumonia, a full recov-
ery is expected with proper medical treatment, in-
cluding rest, fluids, antibiotics (when appropriate),
Figure 15-5 Nebulized Pentamidine via Respirgard II and adequate nutrition. In general, the outcome is
Nebulizer System good for children with pneumonia, and in 2010 the
2831_Ch15_381-414 13/03/14 3:28 PM Page 399
age-adjusted death rate was 2.2% (64). The vast ma- hypoxemia and respiratory failure” (68). ARDS is
jority of children, 92.5% in one study (65), have no reported in both adults and children; however,
residual disease sequelae. However, children with many clinicians believe that children are under-
underlying chronic disease, immune deficiency, or diagnosed because they are classified according to
viral/bacterial co-infection tend to have a more se- the underlying disease (69). Additionally, the ma-
vere course and may develop lung problems later in jority of children meeting the criteria for ARDS
life. Moreover, some studies have followed previ- first meet the criteria for acute lung injury (ALI).
ously healthy children for 8 to 10 years after they ALI is an umbrella term used for lung damage dis-
were hospitalized with pneumonia and found little playing hypoxemic respiratory failure character-
sequelae (66). ized by bilateral pulmonary infiltrates rich in
Childhood pneumonia remains a global problem. neutrophils and the absence of clinical heart fail-
Further research needs to focus on understanding ure. For these reasons, efforts to understand pedi-
the etiology to aid in the development of vaccines atric ARDS can be challenging. The estimated
and antimicrobial therapy. Additionally, improve- incidence of ALI in the United States is 50,000 to
ment in living conditions, nutrition, and air quality 190,000 cases, with 40% of these patients having
should help further reduce mortality in developing ARDS (70). Despite scientific evidence and mod-
countries. However, there are still critical gaps that ern medical interventions, mortality rates remain
need to be understood—including pathophysiology, high, at 22% to 35% in children (71). Furthermore,
etiology, and epidemiology—to reduce mortality in survival rate varies according to the patient’s age
children (67). and underlying lung injury.
Many conditions or factors cause direct or indi-
rect lung insults and lead to ARDS. Direct lung in-
■ ■ Within 1 hour of admission to the inpatient unit, juries include the following:
Jacob’s RR increases to 75 breaths/min, and he be-
gins to exhibit substernal retractions. SpO2 is now • Near drowning
90% on a 2 LPM nasal cannula. The pediatrician calls • Pneumonia
you to initiate HFNC to increase oxygen delivery and • Inhalational injuries
obtain an arterial blood gas (ABG) value. You start the • Aspiration of gastric contents
HFNC at 6 LPM and an FIO2 of 1.0. An ABG value Indirect lung injuries include:
30 minutes later is pH 7.33, PaCO2 44 mm Hg, HCO3
22.9 mEq/L, PaO2 68 mm Hg. You and the physician • Sepsis
are both concerned about respiratory failure, and • Trauma
you agree to begin CPAP at +5 cm H2O. Within • Pancreatitis
20 minutes, Jacob’s SpO2 has increased to 98%, • Severe bleeding
and FIO2 is weaned to 0.70. His RR has decreased to • Fat embolism (68)
50 breaths/min, and he has no noticeable retractions. The most common etiology of ARDS in children
is a lower respiratory tract infection. In addition, the
severity of hypoxia has been shown to be a strong
Acute Respiratory Distress Syndrome predictor of mortality along with multisystem organ
failure. There is no specific cure for ARDS, so sup-
Acute respiratory distress syndrome is an acute portive measures that encourage resting the lung and
heterogeneous disease that causes an “overwhelm- ensuring optimal oxygen delivery to the end organs
ing pulmonary inflammation leading to severe remain the primary focus.
2831_Ch15_381-414 13/03/14 3:28 PM Page 400
of PEEP needed to achieve maximum benefit with lung distensibility, taken under conditions of no air-
minimum complications has not been established flow. Compliance is calculated as:
(80). It is not unusual to start with a PEEP of 10 cm
H2O for cases of ARDS. If the FIO2 cannot be re- Compliance ( ⌬ volume/Δ pressure
duced to below toxic levels (less than or equal to Where Δ volume = measured VT, and ( pressure =
0.60), PEEP should be increased by 2 cm H2O every plateau pressure – PEEP
10 to 20 minutes until an SpO2 of 88% to 95% can
be maintained or oxygen weaning can be achieved. Pressure Control Modes of Ventilation
An SpO2 of 88% to 95% may be tolerated, and ABG Pressure control ventilation modes can be used in
values should be frequently monitored. The health- assist control (A/C) or synchronized intermittent
care practitioner should pay close attention to the mandatory ventilation (SIMV). The RT sets a PIP,
mean airway pressure (Paw) reading on the ventila- and the delivered VT will vary depending on the
tor. Paw and oxygenation are directly related, so by patient’s lung compliance and airway resistance.
increasing the PEEP, you are directly increasing the Pressure control uses a decelerating flow pattern
Paw. Other ways to increase Paw, listed from the and may deliver the desired targeted VT at a low PIP
most to the least effective, follow: (Fig. 15-7). If a pressure control mode is chosen, the
health-care provider must closely monitor exhaled
• Increase positive end expiratory pressure
tidal volumes and minute ventilation. Changes in
• Increase inspiratory time (TI)
lung compliance or airway resistance will increase
• Increase peak inspiratory pressure (PIP)
or reduce minute ventilation, resulting in undesired
• Increase VT
physiological outcomes. This may include hyper-
• Increase RR
ventilation or pneumothorax for rapid increases in
Whereas PEEP and low VT values play a role in compliance and hypoventilation for decreases in
lung-protective ventilation, the choice of the ventila- compliance. Pressure control modes give health-
tory mode may provide some added benefit. Ventila- care providers greater control over Paw. Because
tor manufacturers have proprietary names for their Paw is directly related to oxygenation, ventilator
modes and change frequently, thus clinicians must changes in these modes can produce predictable
maintain proficiency with the modes in use within changes in oxygenation.
their own institution and understand how each func- Inverse-ratio pressure control ventilation (IRPCV)
tions. Modes that provide decelerating flow patterns may be used to increase Paw when increases in PEEP
may deliver desired VT values while requiring lower are no longer desirable. Increasing the inspiratory
PIP. Ventilator adjustments based on the desired time will result in increased Paw and oxygenation.
physiological outcomes are described in Box 15-2. Note that this ventilator strategy is uncomfortable
Regardless of the mode of ventilation, plateau pres- for the patient, so adequate sedation is necessary.
sures should be monitored regularly for patients with
ARDS. Plateau pressure is the amount of pressure ap- Volume-Controlled Modes of Ventilation
plied to the alveoli and is measured by creating a short A/C and SIMV may be used to achieve a volume
inspiratory pause during a mechanical breath. Plateau target (VT), known as volume-controlled ventila-
pressure is indirectly related to alveolar compliance; tion. The health-care practitioner sets a VT, and the
a higher plateau pressure is indicative of a lower or PIP will vary depending on compliance and resist-
worsening compliance, whereas a lower plateau pres- ance of the lungs. The benefit of using the volume-
sure reflects a higher or improving compliance. controlled mode is that there is a guaranteed set
Plateau pressure can then be used to calculate static minute ventilation (RR ⫻ VT), which makes CO2
compliance. Static compliance is a measurement of management more predictable. Changes in compli-
ance and resistance will result in an increase or de-
crease in airway pressures. The minute ventilation
will not change under these conditions. PIPs may be
Box 15-2 Mechanical Ventilator Adjustments higher in volume-controlled modes than in pressure-
control modes while achieving the same VT. This is
To decrease CO2: To increase O2: due to the accelerating flow pattern use to deliver
the breath (Fig. 15-7).
↑ Tidal volume ↑ FIO2
↑ Respiratory rate ↑ PEEP Volume-Targeted Pressure Controlled Modes of
To increase CO2: To decrease O2: Ventilation
↓ Tidal volume ↓ FIO2 In an attempt to provide the benefits of pressure
↓ Respiratory rate ↓ PEEP ventilation along with the consistent VT delivery of
volume ventilation, a hybrid mode of ventilation was
2831_Ch15_381-414 13/03/14 3:28 PM Page 405
Pressure
Flow
Volume
Figure 15-7 A Comparison of Pressure and Flow Curves for Pressure Control Ventilation,
Volume Control Ventilation, and Volume Targeted Pressure-Control Ventilation
designed. Volume-targeted pressure-control ventila- San Diego, CA), Bilevel (Dräger-Europe, Germany),
tion uses an adaptive pressure delivery algorithm to Bi-vent (Siemens, Washington, DC), and DuoPAP
meet a VT set by the end user. This is also described (Hamilton, Switzerland). A benefit of this mode of
as a dual-control mode of ventilation. Depending ventilation is the encouragement of spontaneous
on the ventilator manufacturer, the mode may be breathing. Spontaneous respirations are independent
called PRVC or AutoFlow on the ventilator and can of the ventilator cycle, similar to a CPAP mode, re-
be used as an A/C or SIMV mode. After a series of sulting in gas distribution that is more dependent on
quick test breaths, the ventilator determines the ap- the active respiratory system drawing gas into the
propriate pressure to use to deliver the targeted VT lungs (81). Spontaneous respirations may allow re-
based on the current calculated compliance and re- cruitment of these dependent lung regions without
sistance of the lungs. The ventilator will adjust the increasing airway pressure. Additional benefits of
pressure by plus or minus 3 cm H2O as lung compli- spontaneous respirations include improved hemody-
ance and resistance change until the volume is namic stability, as seen by higher cardiac output
met or the clinician determines that high- and low- and reduced ventricular load, and better patient-
pressure alarm limits are met. There are two benefits ventilator synchronization, exhibited by decreased
to using this mode for ARDS: It provides the benefit WOB and increased patient comfort. In contrast, his-
of a lower PIP by using the decelerating flow pattern torically advanced modes of ventilation such as high-
of pressure control ventilation, and it assures a set frequency ventilation and IRPCV have required the
minute volume (Fig. 15-7). administration of sedation and neuromuscular block-
If plateau pressures, in any mode, cannot be ades, which inhibit spontaneous respirations and
maintained below 30 cm H2O, alternative modes of cause uneven gas distribution, causing an increase in
ventilation must be considered. Early intervention V/Q mismatch.
with airway pressure release ventilation or high- The goals of APRV are to do the following:
frequency oscillatory ventilation should be consid-
• Increase FRC
ered under these conditions.
• Increase surface area for gas exchange
• Maximize oxygenation and ventilation
Airway Pressure Release Ventilation • Minimize VILI
Airway pressure release ventilation (APRV), or bipha-
The initial settings are determined by the patient’s
sic positive airway pressure, is an alternative mode of
age, Paw during conventional ventilation, and pul-
ventilation that provides a continuous airway pres-
monary dynamics determined by the flow/time
sure to promote alveolar recruitment (oxygenation)
curves. The settings manipulated in APRV are Phigh,
and ventilation/perfusion matching, as well as an
Plow, Thigh, Tlow, and FIO2 (82):
intermittent time-cycled release to augment the
patient’s spontaneous ventilation, hence CO2 clear- • Phigh is the pressure the ventilator will main-
ance. Depending on the ventilator, there are several tain in the lungs during the majority of the
other names, including Biphasic (Avea CareFusion, ventilator cycle, with ranges typically from
2831_Ch15_381-414 13/03/14 3:28 PM Page 406
20 to 35 cm H2O. This setting is designed for end-expiratory lung volumes to increase oxygena-
alveolar recruitment. The initial setting should tion and improve ventilation.
be equal to plateau pressure when on conven- Oxygenation:
tional ventilation.
• Assess PEFR greater than 50% and less than
• Plow is the pressure the ventilator will release to
or equal to 75%.
at short intervals, usually a fraction of a sec-
• Increase Phigh and/or Thigh simultaneously. This
ond, typically set at 0 cm H2O. The move from
will increase Paw, which in turn will increase
Phigh to Plow is designed to allow for a bulk ex-
alveolar volume, surface area, and gas exchange.
halation and CO2 clearance from the large
• Assess hemodynamics and assure adequate
airways.
cardiac output.
• Thigh is the amount of time the ventilator will
maintain the Phigh setting, which typically Ventilation:
ranges from 3 to 5 seconds. A longer Thigh
• Assess PEFR greater than 50% and less than
allows more time for alveolar recruitment.
or equal to 75%.
• Tlow is the amount of time the ventilator will
• If Tlow allows for PEFR of greater than or
allow release of pressure from the airways and
equal to 75%, then increase Tlow to achieve
alveoli. It is typically restricted to between 0.2
50% PEFR.
and 0.6 seconds. The Tlow will be adjusted to
• If PEFR is less than or equal to 50%, then de-
allow enough time for approximately 50% to
crease Tlow to optimize alveolar ventilation.
75% of the gas in the lungs to be exhaled. This
• Increase P (difference between Phigh and Plow)
is assessed by observing the expiratory flow
by increasing Phigh and decreasing Tlow to in-
patterns on the ventilator (Fig. 15-8). If more
crease EELV.
than 75% of the gas in the lungs is exhaled
• Assess sedation to assure spontaneous
during Tlow, then alveolar collapse and mi-
ventilation.
croatelectasis is possible.
• Attempt weaning when FIO2 less than or equal
As a guideline, to maximize alveolar recruitment to 40% with SpO2 greater than or equal to
and gas exchange, the bulk of time (80% to 95%) 95%, or when hypocarbia is evidenced by ABG
should occur at Phigh, while limiting the time at Plow. or capnography results.
The Tlow is adjusted and continuously reassessed by • Decrease Phigh and increase Thigh to decrease
using the peak expiratory flow pattern (PEFR). Full ventilator minute ventilation and increase the
exhalation of all alveolar contents should be avoided patient’s spontaneous minute ventilation.
and is evaluated by visualizing the end of exhalation • Allow APRV to more closely mimic traditional
occurring at a flow rate between 25% and 75% of CPAP settings. This will manifest as a low Phigh
PEFR. A short Tlow is used to prevent alveolar dere- and long Thigh, with fewer drops to Plow.
cruitment and maintain adequate end-expiratory
Multiple benefits are attributed to APRV, includ-
lung volume (EELV). Ventilator-adjustment strate-
ing improved alveolar recruitment and oxygenation
gies focus on manipulating the end-inspiratory and
and decreased VILI because of lower inflating pres-
sures. In addition, APRV facilitates spontaneous
breathing and may improve patient tolerance to me-
chanical ventilation by decreasing patient-ventilator
Pressure (cm H2O)
there is no evidence that HFOV reduces mortality in or left side depending on which side the surfactant
ARDS patients (82). will be administered. Patients should be preoxy-
genated with 100% oxygen for 20 to 60 minutes
Glucocorticoids until a SpO2 of 100% or a plateau is reached. Vital
Steroids are still controversial in the literature, and signs, including HR, RR, SpO2, blood pressure,
there is no real consensus on their role in ARDS. end-tidal CO2, VT exhaled, and PIP, should be
There is no benefit regarding survival, and use of monitored, and intra-administration interventions
steroids may increase mortality. Great caution must should be performed based on their results. In the
be used if treating ARDS patients with steroids (85). event of oxygen desaturation with bradycardia, the
patient should be suctioned and administration
Surfactant held until the patient recovers. The patient should
There may be efficacy in the delivery of not be suctioned for 60 minutes after administra-
exogenous surfactant for ARDS since there is evi- tion to allow dispersion of the surfactant to the
dence of type II pneumocyte damage and surfac- alveoli. Patients in pressure-controlled modes of
tant deactivation. BAL studies in patients with ventilation need to be monitored for increasing ex-
ARDS have shown decreased levels of surfactant haled VT. Rapid increase in pulmonary compliance
protein A (SP-A) and surfactant protein B (SP-B) (86). may cause the lung to overdistend, resulting in
One prevalent pathway of surfactant dysfunction pneumothorax.
in lung injury is through biophysical or chemical
interactions with substances present in the alveoli Nitric Oxide
as a result of permeability edema or inflammation Nitric oxide (NO) is an inhaled selective pul-
(86). The goal of surfactant replacement in pa- monary vasodilator that alters levels of cyclic guano-
tients with ARDS is to decrease surface tension sine monophosphate (cGMP) in the pulmonary
in the alveoli and increase surface area for gas vasculature creating vasodilatation. This increases
exchange. If this can be accomplished, plateau blood flow to the ventilated regions of the lung and
pressures should be able to be maintained below increases oxygenation. The half-life of NO is ex-
30 cm H2O. Most research has concentrated on tremely short (approximately 5 seconds), and it rap-
increased oxygenation and decreased mortality as idly binds with hemoglobin, deactivating it; thus, the
their primary outcomes. The dose of surfactant for effects are limited to the pulmonary vasculature (86).
ARDS is still controversial, but in a recent study Doses used to treat ARDS are usually between 10
by Wilson and colleagues, Calfactant was delivered and 20 ppm, although doses as low as 1 ppm im-
at 10 mL/kg for patients less than or equal to 10 kg prove oxygenation (68). Current literature reports
and 80 mL/m2 for patients greater than 10 kg (86). increased oxygenation; however, there is no reported
A meta-analysis of surfactant therapy in children decrease in mortality (68).
with acute respiratory failure including bronchioli- Some of the toxic effects of NO delivery that need
tis and acute lung injury showed decreased mortal- to be monitored during delivery are methemoglobin
ity, improved oxygenation, increased ventilator-free (MetHb) formation and nitrogen dioxide (NO2).
days, and decreased duration of mechanical venti- MetHb is formed when NO binds with it, thus co-
lation (68, 86). Surfactant replacement may hold oximetry must be performed when therapy is initi-
promise in the future treatment of ARDS. During ated and then daily during therapy. Therapy should
delivery, the patient should be monitored for ad- be discontinued when MetHb levels are greater
verse effects, including: than 5%. NO2 is a toxic by-product formed when
NO combines with oxygen. When NO2 mixes with
• Hypoxemia
oxygen and water, nitric acid is formed (HNO3). To
• Decreased ventilation
minimize this reaction and reduce the patient’s risk
• Bradycardia
of exposure, the delivery system must be purged be-
• Pulmonary hemorrhage
fore use. Ventilator flow rates should be high enough
• Pneumothorax
to keep a fresh gas flow and decrease the reaction be-
The route of administration is direct instillation tween O2 and NO molecules. Other factors that in-
via the endotracheal tube. Delivery of the ordered crease risk of exposure to NO2 include high FIO2
dose may take 20 to 60 minutes. Regurgitation up and high doses of NO (above 80 ppm). Monitor
the endotracheal tube is a sign that the dose is being alarm limits should be set to warn of NO2 levels
administered too quickly, and the practitioner 3 ppm or greater. Current delivery systems can de-
should halt administration until the endotracheal liver precise concentrations of NO and reduce the
tube clears. The dose should be split into two sy- risk of exposure to NO2. The delivery systems ensure
ringes, one for the right lung and the other for the a consistent concentration of NO in parts per million
left. The patient is positioned laterally on the right regardless of minute ventilation.
2831_Ch15_381-414 13/03/14 3:28 PM Page 409
■■ Critical Thinking Questions: Jacob Smith intravenous catheter and routine blood culture.
Jennifer is given a sterile sputum culture sample
1. What would you have suggested as the next step
cup and asked to spit mucus in the cup if possi-
in therapy if CPAP had not improved Jacob’s res-
ble. Her mom is encouraged to help her obtain
piratory distress?
the sample while keeping the cup as sterile as
2. Would you expect Jacob to have any long-term
possible.
sequelae from his bronchiolitis? Is there anything
his family should be aware of regarding his respi- • If Jennifer is unable to provide a sputum
ratory care for the next several years? sample spontaneously, what would you
3. If Jacob’s SpO2 had remained greater than 92% recommend as the next step to obtain a
throughout his ED visit, do you think that would specimen?
have changed the course of his care? Should he
Jennifer is moved to the school-aged inpa-
have still been admitted to the hospital?
tient unit and maintained at with a 3L NC. You
encourage Jennifer to cough for you, and you
hear a loose, uncontrollable, and nonproductive
cough. Auscultation still reveals crackles in
the right-middle and lower lobes. Chest radi-
◗● Case Studies and Critical ograph is returned and confirms the diagnosis
Thinking Questions of pneumonia.
•What additional therapies might you suggest
■ Case 1: Jennifer Dodson for Jennifer?
Jennifer Dodson is 5 years old and weighs
■ Case 2: Megan Knox
20 kg. Her mother brought her to the ED after
Megan is 10 years old and weighs 45 kg. She
visiting Jennifer’s pediatrician. Jennifer is exhibit-
has been transported by helicopter to the ICU
ing increased WOB, decreased breath sounds
for management of respiratory failure with refrac-
with crackles in the right-middle and right-lower
tory hypoxemia. Upon arrival, she is being hand-
lobes, and general malaise. In triage, her physical
ventilated with a 6.0 cuffed endotracheal tube
examination is notable for temperature 39.0°C,
with FIO2 of 1.0 at a rate of 25 breaths/min. Vital
altered mental status, nasal flaring, marked sub-
signs are HR, 130 bpm; SpO2, 85% to 87%;
sternal and intercostal retractions, respiratory
blood pressure, 85/55 with vasopressor therapy,
rate greater than 40 breaths/min, HR of 130
and capillary refill time of 5 to 6 seconds. Her
bpm, blood pressure of 115/85 mm Hg, SpO2
breath sounds reveal bilateral course crackles
of 88% in room air, and capillary refill of less than
via auscultation and no WOB. She is heavily
2 seconds. Using appropriate universal precau-
sedated with fentanyl and midazolam. Megan
tions (e.g., gown, gloves, and mask), you initiate
is moved to the ICU bed and placed on me-
a nasal cannula at 3 LPM and sit her upright.
chanical ventilation.
These maneuvers increase her SpO2 to greater
than 95%. • What initial ventilator settings would you rec-
The physician assesses the past medical his- ommend for Megan?
tory and history of present illness. The history is
After Megan is placed on mechanical ventila-
unremarkable: Jennifer was a term newborn and
tion, the physician orders ventilator parameters of
has no prior admissions, no prematurity, and
volume control, VT 350 mL, rate 25; PEEP, 10 cm
normal development and immunizations. Her
H2O; and FIO2, 100%. She orders a chest radi-
mother states that Jennifer has a 2-week history
ograph and laboratory studies including blood
of cold symptoms, including nasal discharge,
cultures, complete blood count with differential,
slight fever, and cough. Today, she had worsen-
metabolic panel, and ABG test. After the ABG
ing of respiratory symptoms, including a rapid
test and chest radiograph are completed, the
respiratory rate, wheezing, and increased respi-
physician asks you to perform PaO2/ FIO2 ratio
ratory effort (e.g., intercostal retractions and
and Murray score to determine the degree of
nasal flaring), along with decreased oral intake
severity of Megan’s respiratory illness. The chest
and activity level.
radiograph reveals bilateral interstitial and alveolar
• Based on these clinical findings, what is infiltrates without cardiomegaly. ABG values are
Jennifer’s most likely differential diagnosis? 7.27/58/26.3/150.
After the physician has completed his assess- • What is Megan’s PaO2/ FIO2 ratio?
ment, a chest radiograph is ordered, along with an • What is her Murray score?
2831_Ch15_381-414 13/03/14 3:28 PM Page 411
Multiple-Choice Questions
1. A 6-month-old girl is brought to the pedi- c. Respiratory syncytial virus
atric ED by her grandmother. She has had d. Haemophilus influenzae
a low-grade fever, runny nose, and a cough 5. An 8-year-old boy has been transferred to the
for 3 days. She has refused finger foods since PICU for pneumonia and impending respira-
the start of the fever and has refused bottles tory failure. You start him on CPAP plus 5 cm
for the last 6 hours. Vital signs are HR, H2O and an FIO2 of 0.75. Which of the follow-
158 bpm; SpO2, 91%; and RR, 65 breaths/min. ing would be evidence of improved respiratory
On physical examination, you note subster- status?
nal retractions and decreased breath sounds a. Improved SpO2
with inspiratory and expiratory wheezing. b. Decreased RR
The baby seems sleepy and difficult to c. Decreased FIO2 to less than 0.60
arouse. The ED physician is caring for a d. Decreased WOB
patient in a critical care room but asks for e. All of the above
your impressions and recommendation re-
garding admitting the baby. What should 6. Which of the following are clinical characteris-
you suggest? tics necessary for a diagnosis of ARDS?
a. Observe for 1 to 2 hours in the ED, assessing I. Bilateral infiltrates on chest radiograph
for signs of improvement II. Unilateral infiltrates on chest radi-
b. Admit to the pediatric in-patient unit ograph
c. Discharge home III. Evidence of left atrial hypertension
d. Admit to the ICU IV. Normal left atrial pressures
V. Acute onset of symptoms
2. Which of the following signs are indicative of VI. Hypoxia
severe bronchiolitis? a. I, III, V, VI
I. SpO2 less than92% b. II, III, VI
II. RR 60 to 70 breaths/min c. I, IV, V, VI
III. Inspiratory and expiratory wheezing d. II, IV, V, VI
IV. Intercostal retractions
a. I, III 7. Chest radiograph findings for pneumonia in-
b. II, IV clude all of the following except:
c. I, II, III a. Patchy and segmental or nonsegmental with
d. I, III, IV the presence of airspace opacification.
b. Diffuse interstitial or peribronchial
3. A 4-year-old with pneumonia has an SpO2 of infiltrates.
90% on room air and thick nasal and airway c. Patchy infiltrates attributed to atelectasis.
secretions that are difficult to clear. What d. Lobar or alveolar consolidation.
would be the best oxygen delivery device to
increase SpO2 greater than 95%? 8. The benefit of pressure-controlled over
a. NC at 1 LPM volume-controlled modes of ventilation is:
b. Simple face mask at 3 LPM a. Breath-to-breath VT variations.
c. Non-rebreather at 15 LPM b. Decelerating flow patterns during manda-
d. HFNC at 8 LPM tory breaths.
c. Consistent PIPs despite changes in lung
4. What is the most common bacterial pathogen compliance and airway resistance.
causing pediatric pneumonia? d. All of the above.
a. Staphylococcus aureus
b. Streptococcus pneumonia
2831_Ch15_381-414 13/03/14 3:28 PM Page 412
9. The benefit of volume-control over pressure- provides the following: pH, 7.23; PaCO2,
control modes of ventilation is: 62 mm Hg; PaO2, 55 mm Hg. Which of the
a. Consistent minute ventilation despite following would be the best ventilator setting
changes in lung compliance and airway changes to improve acid-base status and
resistance. oxygenation?
b. Accelerating flow patterns during manda- I. Increase Phigh
tory breaths. II. Decrease Thigh
c. Breath-to-breath variation in PIPs. III. Increase Thigh
d. All of the above. IV. Increase FIO2
10. A 12-year-old patient with ARDS caused by V. Increase Tlow
near drowning has been on APRV for 4 days. a. I, II, IV
Goal blood gas values are pH greater than b. I, IV, V
7.25, PaCO2 less than 55 mm Hg, and PaO2 c. I, II, IV, V
greater than 60 mm Hg. A routine ABG result d. I, III, IV
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Chapter 16
Pediatric Infectious
Airway Diseases Stacey Mann, BS, RRT
415
2831_Ch16_415-432 13/03/14 3:40 PM Page 416
Chapter Objectives
After reading this chapter, you will be able to:
1. Identify the “4 Ds” referred to in the clinical presentation of epiglottitis.
2. Identify similarities and differences in the clinical presentation of epiglottitis, croup, and bacterial tracheitis.
3. Identify the most definitive way to diagnose both epiglottitis and bacterial tracheitis.
4. Differentiate between the radiographic findings of epiglottis, croup, and bacterial tracheitis.
5. Identify the most common organism associated with epiglottitis and discuss why there has been a decline
in outbreak of the disease over the last several years.
6. List four common viruses that cause croup in the pediatric patient population.
7. Use the Westley croup score to assess a patient’s symptoms of croup.
8. List three possible treatments for croup that respiratory therapists can administer.
9. Identify one microorganism found today that may contribute to the changing epidemiology and virulence
of bacterial tracheitis.
A
cute infections of the respiratory tract are summary of important clinical distinguishing features
common in pediatric patients. Upper and between croup, epiglottitis, and bacterial tracheitis
lower airway infections are commonly en- can be found in Table 16-1.
countered in the ED. Visits for respiratory disease
account for 10% of all pediatric ED visits and 20%
of all pediatric hospital admissions (1). The severity
of upper respiratory tract infections can range Box 16-1 Infectious Causes of Acute Upper
from a mild, self-limited disease to potentially life- Airway Obstruction in Children
threatening airway obstruction. The various upper
airway infections can pose significant diagnostic and Epiglottitis (supraglottitis)
therapeutic challenges because they present with Croup (laryngotracheobronchitis)
similar symptoms but require vastly different med- Bacterial tracheitis
ical management. As with many infections, the Retropharyngeal abscess
primary challenge with pediatric upper airway infec- Peritonsillar abscess
tions lies in identifying the causative pathogen Laryngeal diphtheria
and determining the extent of disease progression. Infectious mononucleosis
Because of these challenges, a working diagnosis is
2831_Ch16_415-432 13/03/14 3:40 PM Page 417
Onset Gradual viral symptoms Rapid onset 6–12 hours Viral symptoms followed
1–7 days by rapid deterioration
Typical age at onset 6 months to 3 years 2–7 years 6 months to 8 years
Seasonal occurrence Late fall to winter Throughout the year Fall to winter
Causative agents Parainfluenza Hib (typically) S. aureus
RSV S. pneumoniae H. influenzae
Adenovirus S. aureus M. catarrhalis
Influenza A & B K. pneumoniae S. pneumoniae
H. parainfluenzae
Beta-hemolytic streptococci
(groups A, B, C, and F)
Pathology Subglottic edema Inflammatory edema of Thick, mucopurulent
supraglottis membranous tracheal
secretions
Radiographic findings Subglottic narrowing on Thickening, rounding of Subglottic narrowing on
AP view; steeple sign epiglottis; thumb sign AP view; hazy irregular soft
tissue densities; pneumonia
Fever Low grade High fever High fever
Cough Barking or seal-like None Present
Sore throat None Severe None
Drooling None Frequent None
Posture Any position Sitting forward, mouth open, Any position
neck extended (tripod position)
Voice Normal or hoarse Muffled Normal or hoarse
Appearance Nontoxic Toxic Toxic
Root of
tongue
Nasopharynx Epiglottis Vallecula
Oropharynx Pharynx
Aryepiglottic
Vocal cords
fold
Tongue
Epiglottis Glottis Trachea
Larynx
Interarytenoid
Esophagus notch Esophagus
Box 16-2 Progressive Signs and Symptoms capable of obtaining an airway, and any anxiety-
of Epiglottitis provoking maneuvers such as phlebotomy and
radiographs should be avoided until an airway has
• Severe throat pain been established. Also, in patients who have mild-
• Fever to-moderate respiratory distress or in older, cooper-
• Irritability ative patients, the classic cherry red epiglottis may
• Drooling be visualized with gentle compression of the anterior
portion of the tongue with a tongue depressor
(Fig. 16-2A). In these patients, radiological exami-
nation can confirm the diagnosis and rule out for-
eign body, retropharyngeal abscess (the collection of
breathing, is a chief complaint of patients with pus in the back of the throat), or croup. Lateral neck
epiglottis. Speech is limited because it is painful, and radiographs taken with hyperextension of the neck
dysphonia or disorders of the voice can occur. The are the single most-useful study and may demon-
voice tends to be muffled rather than hoarse (as in strate the classic thumb sign, indicative of the thick-
children with croup; discussed later in this chapter). ening and rounding of the epiglottis (Fig.16-2B).
Stridor is a late finding and signals near-complete It should be noted, however, that with this practice,
airway obstruction. rapid respiratory compromise may develop in a
Children with epiglottitis are usually anxious, delayed manner, necessitating emergency airway
which is a strong indication that their airway is sig- intervention (6).
nificantly compromised and may, in fact, worsen the
degree of upper airway obstruction.
Past and Recent Medical History
Secondary sites of infection are present 50% of the
time, including meningitis (inflammation of the
spinal cord and brain), otitis media (middle-ear in-
fection), pneumonia, and cellulitis (infection of the
skin) (3).
Laboratory Test Results
Patients with epiglottitis have elevated leukocyte
white blood cell (WBCs) counts and frequently
have positive blood cultures for the bacterial
pathogen (4).
Airway and Respiratory Symptoms
The definitive diagnosis of epiglottitis requires direct
visualization of a red swollen epiglottis under laryn-
goscopy (4). Because of the higher likelihood of air-
A
way obstruction in children, in patients who exhibit
a significantly compromised airway, direct examina-
tion of the epiglottis should be attempted only in an
interdisciplinary collaboration with an anesthesiol-
ogist and an otolaryngologist in a controlled setting,
such as an operating room (OR), which allows for
the establishment of an artificial airway (4). The
child should be attended at all times by someone
Drooling
Dysphagia B
Dyspnea Figure 16-2 Neck Radiograph (A) and Endoscopic
Dysphonia View (B) of Epiglottis (Source: International Journal of Pedi-
atric Otorhinolaryngology, with permission)
2831_Ch16_415-432 13/03/14 3:40 PM Page 420
■ ■ Upon the resident taking the history and completing Airway Stabilization and Management
the physical examination, you learn that Timmy was
When epiglottitis is suspected, immediate coordi-
seen by his pediatrician 3 days ago and is currently
nated care should be arranged between otolaryngol-
being treated for an otitis media with amoxicillin. The
ogy, anesthesiology, critical care intensivists, and
physician asks Timmy’s mom if he is up to date with
RTs to protect the patient from complete airway ob-
his immunizations, and she says he has not gotten
struction. It is important for RTs to aid in looking
all of his Hib vaccines owing to a national shortage.
for the early warning signs of respiratory distress and
Timmy begins to drool and is starting to have stridor
airway obstruction. A good therapist can aid the
on inspiration. You pull the physician aside and say,
physicians in their diagnosis by recognizing the clin-
“I am worried about being able to maintain Timmy’s
ical signs and symptoms of epiglottitis and voicing
airway, and I think we should get the attending
their concerns regarding proper airway management
physician involved in his care. Now that he is drool-
to the physician.
ing, I am concerned about epiglottitis, which is an
Patients for whom epiglottitis is suspected should
airway emergency” (Teamwork 16-1). Based on
be expeditiously transported to the OR to secure an
what you both have just learned in Timmy’s history
airway. In the OR, all emergency airway equipment
and physical examination, the resident agrees, and
should be available and set up in advance, including
you get the attending physician while he stays with
the following:
the Timmy to monitor his airway.
• Oral airways
• Laryngoscopes
• Rigid bronchoscope (a hollow stainless steel
Management and Treatment scope used to visualize the airway and typically
The typical management of epiglottitis includes remove foreign bodies or dilate the airway and
rapid airway stabilization, treatment of hypoxemia, place stents)
and the administration of pharmacological interven- • Flexible bronchoscope (a longer and thinner
tions aimed at minimizing airway edema. scope than the rigid bronchoscope that tends
to be preferred because of its smaller size and
Oxygen Therapy ability to navigate into individual lobes or
Oxygen is a supportive therapy used to treat hypox- bronchi of the lung, and because it causes less
emia in these patients while assessing and stabilizing discomfort to the patient)
the patient’s airway. • Instruments for cricothyroidotomy/tracheotomy
Inhaled Medications
The use of nebulized racemic epinephrine has
been well established as an effective, albeit tempo-
rary, means of relieving upper airway obstruction by
local vasoconstriction and decreasing the mucosal
edema (4). Racemic epinephrine has been available
in the United States since 1971. The alpha-adrener-
gic effect on mucosal vasculature is highly effective
in reducing airway edema (3). Due to the potential
for side effects, including agitation, tachycardia, and
hypertension, the use of racemic epinephrine is com-
monly reserved for patients who have moderate-to-
severe respiratory distress per their Westley croup
score (6). The most common pediatric dosage of neb-
ulized racemic epinephrine is 2.25% (0.25 to 0.75 mL
in 2 mL normal saline), with clinical effect lasting up
to 1 to 2 hours (9).
Treatment with racemic epinephrine causes rapid
improvement in clinical status (within 10 to 30 min-
utes) and appears to decrease the need for intubation
A
(9). The effect, however, is transient because epi-
nephrine has a short half-life and disappears within
2 hours of administration. A single dose may relieve
the symptoms of some children in considerable dis-
tress, but others may need repeat doses.
In the past, children treated with racemic epineph-
rine have been hospitalized for observation because
of the potential for rebound edema, which refers to
tracheal edema that returns to baseline after 1 to
2 hours of administration of racemic epinephrine (9).
Recent studies, however, suggest that these patients
may be safely discharged after a 3- to 4-hour obser-
vation period, provided that they are stridor free and
show no signs of respiratory distress and that the
parents can provide reliable monitoring and return
B to the hospital if necessary (11).
Figure 16-3 Neck Radiograph of Croup Taken During
Inspiration (A) and Exhalation (B) (Courtesy of Jane
Corticosteroids
Benson, MD) Because of their significant anti-inflammatory
effects, corticosteroids are commonly prescribed for
the treatment of croup. They can be administered by
Oxygen Therapy way of nebulization or via oral or IV routes. Although
Traditionally, croup has been treated with humidified the exact mechanism of action for corticosteroids is
air, as either heated or cool mist. The presumed effect unclear, they have been shown to reduce submucosal
is to soothe the inflamed mucosa, decrease coughing edema and decrease the inflammatory reaction (3). In
due to irritation, and liquefy secretions, making them general, because the result of steroid administration
easier to expectorate. Unfortunately, no scientific ev- will not be appreciated for at least 3 hours, they are
idence exists to support the theory that humidified usually administered with racemic epinephrine (3).
air has any effect on subglottic mucosa or that it There has been much debate over the past several
positively influences patient outcome. Furthermore, years about the efficacy of corticosteroids in the
mist tents can increase respiratory distress by provok- treatment of croup. Several studies have shown sub-
ing anxiety because of separation from the parents stantial improvement in children with severe croup
and may lessen the ability to effectively monitor the treated with corticosteroids regardless of their route
2831_Ch16_415-432 13/03/14 3:40 PM Page 425
endotracheal tube (ETT) be used. Extubation can Box 16-4 Common Pathogens Causing
usually be accomplished within 2 to 3 days, when an Bacterial Tracheitis (7,12)
air leak around the ETT can be detected.
• Staphylococcus aureus
Course and Prognosis • Haemophilus influenzae
Since the early 1900s, advances in management of • Alpha-hemolytic streptococcus
croup have transformed this condition from a deadly • Streptococcus pneumonia
upper airway disease to a relatively benign self-limited • Moraxella catarrhalis
condition (6). Most patients with croup can be treated • Streptococcus pneumoniae
in the primary care or ED setting using supportive
treatment. For patients in an outpatient setting who
have severe symptoms that do not resolve over 2 to and extent of the damage to the tracheal mucosa, the
4 hours with corticosteroids and racemic epinephrine, patient’s age and underlying medical condition, and
admission to the ICU and treatment with heliox, it the size of the airway (21).
may be necessary to use IV antibiotics and intubation. The most common pathogen associated with bac-
Mortality from croup in intubated patients is rare, terial tracheitis is S. aureus, although several others
with rates reported as low as 0.5% (13). have been implicated (Box 16-4).
It is common for a child with a croup diagnosis to In one of the largest recent multicenter studies out
have recurring croup after the initial bout. Up to 5% of the United Kingdom and Australia, 34 pediatric
of children may have more than one episode. Pa- patients with bacterial tracheitis were evaluated. In
tients who are younger than 6 months when they first this series, S. aureus was the most common bacteria
present with croup, those who have an unusually present, infecting 62% of the patients studied in the
long duration of symptoms (greater than 1 week), UK and 55% of the patients studied in Australia (22).
those who have unusually severe symptoms, and Two patients were isolated for Hib. Eighty-five
those who have recurrent croup should be evaluated percent of the patients studied also had viral testing
for congenital or acquired airway narrowing (6). For performed. Thirty-one percent of these patients had
patients with recurring symptoms, airway examina- positive viral results, with 13.8% with influenza A,
tion with endoscopy is indicated. Ideally, the exam- 6.9% with parainfluenza type I, 6.9% with parain-
ination is delayed for 3 to 4 weeks so that persistent fluenza type III, and 3.5% with adenovirus (22). This
inflammatory changes do not mask any anatomical study illustrates that bacterial tracheitis often presents
abnormalities, such as subglottic stenosis. as a secondary illness following an acute respiratory
viral infection. The viral illness is believed to cause
Bacterial Tracheitis transient alterations in the immune response that pre-
disposes the patient to bacterial infection (21). This
Bacterial tracheitis, also known as bacterial laryngo- theory is strongly supported by the observation that
tracheobronchitis, pseudomembranous croup, or bac- bacterial tracheitis cases occur most often during
terial croup, was first described in detail by Jones the winter months when viral upper respiratory tract
and colleagues in 1979 (19). Although it is a rare dis- infections are more prevalent (21).
ease, clinicians should consider the diagnosis in any
child with respiratory distress. The peak incidence is Clinical Manifestations
in the fall and winter, affecting children from age The clinical presentation of bacterial tracheitis has
6 months to 8 years, with the average age of 5 years features of both epiglottitis and viral croup.
(3). Furthermore, in a study by Gallagher and
Meyer, males were diagnosed with two times more Patient History
frequency than females (20). Bacterial tracheitis is Children with bacterial tracheitis typically present
characterized by marked subglottic edema and thick with a several-day history of upper respiratory symp-
mucus or pus-containing secretions (11). toms such as a low-grade fever, cough, and stridor
(similar to patients with croup) (10). Presentation for
Pathophysiology medical attention is often precipitated by an acute
In bacterial tracheitis, bacteria invade the trachea deterioration, when a patient develops a high fever,
and stimulate both local and systemic inflammatory toxic appearance, and evidence of airway obstruc-
responses. This results in production of thick, mucop- tion. These patients’ infections are generally more
urulent exudates (secretions with a high concentration toxic than those with croup.
of mucus and pus), ulceration, and sloughing of the
tracheal mucosa (21). This can result in a variable de- Physical Examination
gree of upper airway obstruction. The severity of the Other findings on physical examination include stri-
upper airway obstruction depends on the location dor, hoarseness, cough, and tachypnea (21). Unlike
2831_Ch16_415-432 13/03/14 3:40 PM Page 427
an ETT in place because suctioning can be done fre- and the most recent and largest case studies reported
quently and aggressively, preventing occlusion of the from 2004 to present show no mortality associated
airway by thick exudates (21). When intubation is with the illness. The improvement in mortality rate
indicated, the ETT selected needs to be a smaller size likely is due to the early recognition and improved
than normally chosen for the age to account for the treatment of the infection with aggressive airway-
airway inflammation present (21). Younger children clearance techniques and early initiation of broad-
are more likely to require intubation owing to the spectrum antibiotics (21). Full recovery with no
small size of their airway. The level of comfort of the long-term morbidity is expected in the vast majority
attending physician and the availability of a skilled of children with bacterial tracheitis, especially if
bronchoscopist also play a major role in the decision there are no complications during the acute illness.
regarding intubation (21). Children managed with- The most frequent complication associated with
out endotracheal intubation need close observation bacterial tracheitis is pneumonia. Other less common
in a hospital with expertise in pediatric airway man- complications include acute respiratory distress syn-
agement (21). drome (ARDS), septic shock, toxic shock syndrome,
Intubation is often required for 3 to 7 days, until the pulmonary edema, pneumothorax, and, rarely, car-
patient is afebrile, there is an air leak present around diopulmonary arrest (21).
the ETT, and there is a decrease in the quantity and In a retrospective study out of Vermont Chil-
viscosity of secretions (3). Occasionally, additional en- dren’s Hospital, between 1997 and 2006 there were
doscopy or bronchoscopy may be needed to remove 35 patients with potentially life-threatening upper
pseudomembranous material. While patients are intu- airway infections admitted to the PICU with the
bated, they will require basic rest settings on the me- diagnosis of epiglottitis (n = 2), viral croup (n = 16),
chanical ventilator to maintain adequate arterial blood and bacterial tracheitis (n = 17) (24). Twenty of these
gas results. patients developed respiratory failure. Fifteen of
Children managed with bacterial tracheitis with- these patients (75%) had bacterial tracheitis, three
out endotracheal intubation need close observation patients (15%) had viral croup, and two patients
in a tertiary care center and generally get admitted to (10%) had epiglottitis (24). As shown by these data,
the PICU for 48 to 72 hours for close monitoring. bacterial tracheitis was the most common potentially
During their ICU admission, these children are typ- life-threatening upper airway infection in children.
ically maintained on IV antibiotics and basic oxygen Four patients developed ARDS, with two requiring
therapy, if indicated. In a 2010 retrospective chart re- high-frequency oscillatory ventilation. All four pa-
view out of Boston Children’s Hospital, six patients tients with ARDS developed multiple-organ dys-
ranging in age from 10 months to 16 years were ad- function syndrome, but all patients in this study
mitted to the PICU and treated for bacterial tra- survived.
cheitis between January 2009 and March 2009 (23). The increasing burden of serious MRSA infections
All patients underwent urgent laryngoscopy and and other bacterial “superbugs” may contribute to the
bronchoscopy for removal of mucopurulent secre- changing epidemiology and degree of severity of this
tions. All patients were treated with broad-spectrum disease. Bacterial tracheitis should be considered as
IV antibiotics. None of the patients required urgent part of the differential diagnosis in all children who
intubation, although one was kept on a ventilator for present with acute life-threatening upper respiratory
48 hours until disease resolution was confirmed with infection. With early intervention and treatment, prog-
laryngoscopy and bronchoscopy (23). No patients re- nosis is good, with low rates of long-term morbidity.
quired tracheotomy, and there were no cardiopul-
monary arrests. The mean hospital stay was 4.8 days,
and all patients were transitioned to oral antibiotics
for 10 to 14 days after discharge. This study showed ■ ■ Timmy is monitored closely in the PICU, and
that, although bacterial tracheitis is a potentially fatal within 48 hours of being intubated, he is responding to
illness, early identification and consistent, proactive the antibiotics and steroids. He no longer has a fever
treatment and management in a controlled operative and has developed an air leak around his nasal tra-
environment might be able to decrease the rate of cheal tube. Timmy is awake and anxious to be extu-
complications and the need for intubation in pedi- bated. You speak with the PICU team, and they agree
atric patients. to extubate him. You gather all of the emergency air-
way equipment at the bedside just in case he needs to
be reintubated. Timmy is extubated without difficulty
Course and Prognosis and placed on 0.40 FIO2 via aerosol face mask, and
The mortality rate due to bacterial tracheitis has de- his SpO2 is 99%. Within 2 hours, you are able to wean
creased dramatically since the 1900s. In the early Timmy to room air. He is discharged from the hospital
20th century, the mortality rate was as high as 10% the following day.
to 40% (21). This rate has declined slowly over time,
2831_Ch16_415-432 13/03/14 3:40 PM Page 429
■■ Critical Thinking Questions: Timmy Jones to the pediatric ED for your 12-hour shift. At ap-
proximately 0900, Jacob, a 3-year-old boy, pre-
1. If Timmy had presented to the ED with mild symp-
sents to the ED with difficulty breathing. He has
toms of upper airway obstruction and you were
had a fever and runny nose for the past 2 days.
unsure of the diagnosis being epiglottitis, what
Overnight he has had worsening respiratory dis-
could you have recommended to the physician
tress and now has inspiratory stridor at rest.
instead of immediate airway protection?
Physical examination of Jacob reveals that he
2. If the ENT doctor and anesthesiologist were unable
is alert, with stridor at rest. He is not drooling. His
to intubate Timmy in the OR because of swelling
vital signs are as follows:
and edema in the airway, what else could be done
to protect his airway? • RR of 60 breaths per minute
3. If Timmy did not show a quick response to the • SpO2 92% on room air
antibiotics and steroids, what would you expect to • HR of 140 bpm
be true of his airway? • Temperature of 39.2°C (102.6°F)
4. How do you think Timmy would have presented dif-
ferently if he had viral croup instead of epiglottitis? His oropharyngeal examination is normal. His
5. If Timmy had presented with a high fever and slight chest examination reveals mild intercostal and
cough, but had no drooling and was comfortable supraclavicular retractions with decreased air
lying down, what would you suspect his diagnosis exchange. He is noted to have some cyanosis
to be? with agitation. The remainder of his examination
is unremarkable.
• What do you suspect is Jacob’s primary
diagnosis?
• What is Jacob’s Westley croup score?
◗● Case Studies and Critical • What treatment would you recommend for this
Thinking Questions patient?
• Is Jacob ready to be discharged to home?
Case 1: Ryan Smith Case 3: Stephanie Johnson
You are working as the floating RT in a small 250- You are an RT in a 400-bed hospital covering the
bed community hospital. You are called to the ED ED and part of the 12-bed ICU. You receive a
to assess an 8-year-old boy, Ryan Smith. Ryan is a page to the ED and respond to find a 9-year-old
previously healthy little boy who is up-to-date with girl, Stephanie, who has presented to the ED in
all of his immunizations. He presents today with a respiratory distress. Stephanie’s vital signs are as
chief complaint of sore throat and fever of 103°F, follows:
which came about abruptly in the last 4 hours.
While taking the history and performing the • RR of 30 breaths/minute
physical examination, you learn that Ryan has had • SpO2 of 89% on room air
a history of runny nose and nasal congestion for • HR of 120 bpm
the past 3 days. He has pharyngeal redness, and • Temperature of 38.1°C (101.5°F)
a rapid strep test is performed and comes back
On taking her history and performing a physical
negative. A soft tissue neck radiograph is obtained
examination, you learn that Stephanie has had
that shows mild thickening of the epiglottis and
upper respiratory tract symptoms, a sore throat, a
aryepiglottic folds.
low-grade fever, and mild hoarseness for the past
After 2 hours of observation in the ED, Ryan
3 days. Stephanie has mild-to-moderate respira-
begins to have difficulty swallowing and develops
tory distress and has inspiratory stridor and a non-
drooling. He now has stridor, wheezing, and a
productive cough. She is found laying flat on the
muffled voice.
stretcher and has moderate substernal retractions.
• What do you think is Ryan’s primary diagnosis? Over the next few hours, Stephanie’s breathing
• What should the caregivers in the ED do to help becomes more labored, and her temperature rises
treat Ryan? to 39.4°C (103°F).
• When the PICU transport team arrives, what
• What do you think is Stephanie’s primary
should they do prior to transporting Ryan back
diagnosis?
to their facility?
• What do you think would be an appropriate
Case 2: Jacob Davis way to diagnose Stephanie’s illness?
You are working as a pediatric RT in a large, • What would you recommend to treat
800-bed tertiary medical center and are assigned Stephanie?
2831_Ch16_415-432 13/03/14 3:40 PM Page 430
Multiple-Choice Questions
1. Which of the following is a classic radiographic c. Blood culture
finding of epiglottitis? d. Sputum culture
a. Steeple sign 7. A pediatric patient presents to the ED with the
b. Pneumonia following symptoms of croup: stridor at rest
c. Thumb sign with auscultation, mild retractions, decreased
d. Subglottic narrowing air entry, no cyanosis, and a normal level of
2. Which two types of treatment listed below are consciousness. What is the patient’s Westley
appropriate for patients with croup? croup score?
I. Antibiotics a. 6
II. Corticosteroids b. 4
III. Racemic epinephrine c. 2
IV. Vasopressors d. None of the above
a. I, II 8. Which of the following is not a clinical sign of
b. II, III croup on presentation?
c. III, IV a. Severe toxicity
d. II, IV b. Hoarseness
3. Which of the following clinical signs and symp- c. Barking cough
toms is specific only to epiglottitis? d. Inspiratory stridor
a. Fever 9. Which of the following is the most common
b. Barking cough complication found in patients with bacterial
c. Drooling tracheitis?
d. Inspiratory stridor a. Cardiopulmonary arrest
4. Which of the three upper respiratory infections b. Pneumonia
listed below presents with a history of upper c. Toxic shock syndrome
respiratory symptoms for multiple days? d. ARDS
a. Epiglottitis 10. Which of the following initiatives are most
b. Croup important in treatment and management of
c. Bacterial tracheitis patients suspected of having epiglottitis?
d. Both b & c I. Minimize anxiety-producing procedures
5. Which of the following is not a microorganism II. Endoscopy
that commonly causes bacterial tracheitis? III. Blood cultures
a. S. aureus IV. Radiography
b. M. catarrhalis a. I, II
c. S. pneumoniae b. II, III
d. Respiratory syncytial virus c. II, IV
6. Which of the following is the tool used to make d. All of the above
a definitive diagnosis for both epiglottitis and
bacterial tracheitis?
a. Endoscopy
b. Radiography
Chapter 17
Neuromuscular
Disorders Sharon McGrath-Morrow, MD
Suzanne Preswitch, MD
433
2831_Ch17_433-452 13/03/14 3:39 PM Page 434
Chapter Objectives
After reading this chapter, you will be able to:
1. Discuss the indications for noninvasive ventilation in a patient with a neuromuscular disorder.
2. Identify at least two common genetic diseases that cause neuromuscular weakness.
3. Identify the cause of hypoxia in a patient with an underlying neuromuscular disorder without underlying
lung disease.
4. Determine when to use an insufflation-exsufflation device in a patient with a neuromuscular disorder.
5. Describe how spirometry, maximum inspiratory pressure, and maximum expiratory pressure can help
predict risk of respiratory failure in a patient with a neuromuscular disorder.
6. Describe the significance of a bell-shaped chest radiograph in an infant who presents with hypotonia and
hypoxia.
7. Explain the utility of an overnight sleep study in detecting early chronic respiratory failure in a patient with
a neuromuscular disorder.
8. Describe different mucociliary clearance techniques and their importance in preventing the development
of atelectasis and pneumonia in patients with neuromuscular weakness.
William Stubbs
N
■■ euromuscular disorders are a diverse group
of conditions that affect the function of vol-
You are working in a small rural community hospital untary skeletal muscles. Often, the presen-
and covering the emergency department (ED), which tation of acute illness can be mild. However, medical
is packed with children at the height of flu season. providers need to be aware that these conditions
You are sent to assess a 15-year-old boy, William can often deteriorate, many times very quickly, and
Stubbs. William came to the ED the previous evening, require immediate and definitive treatment.
reporting that his hands and feet felt “weird.” When Respiratory complications and ventilatory fail-
questioned further, he reported that they felt numb ure are frequently the major cause of morbidity and
and tingly. He reported no problems with swallowing. mortality in patients with a neuromuscular disor-
Yesterday, he had no cough, wheezing, or respiratory der. There are many different types of neuromus-
distress. His oxygen saturations were 98% on room cular diseases that afflict the pediatric population.
air. He was seen by the ED physician and sent home Some conditions are genetic (e.g., spinal muscular
with the diagnosis of “viral syndrome.” atrophy [SMA]), whereas others are acquired (e.g.,
William’s parents brought him back to the ED tetanus). Some conditions are progressive with age
today because he is having difficulty walking, with (e.g., Duchenne’s muscular dystrophy [DMD],
persistent tingling. He has no significant past medical limb-girdle muscular dystrophy [LGMD]), whereas
history. He has never had any operations nor been others can be episodic (e.g., myasthenia gravis
hospitalized. His only medications are multivitamins [MG]) or static (e.g., SMA). And some neuromus-
and occasional diphenhydramine for allergies. cular diseases can have an infectious or immune
William’s parents report that he had diarrhea about etiology (e.g., botulism, Guillain-Barré syndrome
1 week ago but was otherwise doing well. [GBS]). See Table 17-1 for an overview of the dis-
William is anxious, and his respiratory rate (RR) is orders discussed in this chapter.
35 breaths/min. His oxygen saturations are in the Identification of respiratory abnormalities and
low 90s on room air. He is noted to have a frequent the initiation of preventative therapies may help
throat clearing. He has a weak cough. Arterial blood stabilize lung function or help slow lung decline in
gas (ABG) test results show a pH of 7.40, with a this vulnerable group of individuals. A decline in
PaCO2 of 35 mm Hg and PaO2 of 75 mm Hg. He is respiratory muscle function can lead to decreased
admitted to the inpatient unit for further observation tidal volume (VT) values and ineffective cough (1).
and diagnostic workup. Therefore, objective measurements of lung func-
tion can be helpful in guiding the initiation of
2831_Ch17_433-452 13/03/14 3:39 PM Page 435
Guillain-Barré Atypical immune response Presents with weak- Support ventilation 4 weeks
syndrome after an infection (C. jejuni, ness in both arms Plasmapharesis
cytomegalovirus, M. and legs, progressing Intravenous im-
pneumonia, H. influenzae, to partial paralysis munoglobulin (IVIG)
and Epstein-Barr virus) No previous significant
Antiganglioside antibodies history
bind to peripheral nerves,
causing impaired function.
Myasthenia Autoimmune disorder Fluctuating muscle Monitor respiratory fail- May be chronic
gravis - Congenital = genetic weakness and fatigue; ure; anticholinesterase Neonatal
mutations begins with ocular and therapy resolves in
- Neonatal = transplacen- facial weakness 2-4 weeks
tal exchange of
immunoglobulins
- Juvenile = chronically
produced serum
antibodies
Tetanus Neurotoxin from C. tetani Trismus Support ventilation Low mortality
spores that enter the Hands clenched Pain management Resolution
body through a wound; Feet dorsiflexed Cardiovascular Few long-term
incubation 3-21 days; Full-body spasms support sequelae
tetanus toxin prevents in- Body rigidity Intramuscular (IM) TIG
hibitory motor neurons Antibiotic
Botulism Bacterial––C. botulinum; Descending flaccid Support ventilation Low mortality
progressive neuroparalytic paralysis over hours Infant = BabyBIG No recurrence
disease; block acetyl- or days Others = antitoxin
choline transmission Starts with constipa- Antibiotics
across neuromuscular tion and difficulty swal-
junction lowing, ptosis, loss of
Food-borne, wound, head control
infant
Muscular Genetic disorder (males); Gradual loss of skeletal Aggressive respiratory Survival to
dystrophy progressive breakdown of and cardiac muscle support 18–21 years,
muscle fibers strength; heart failure - NIV during acute longer with ag-
illness gressive preven-
- Support respiratory tive strategies
failure
- Treat sleep apnea
Spinal - Genetic disorder Proximal bilateral mus- Support respiratory Types I and II -
muscular - Lower motor neuron de- cle weakness, tongue failure (tracheostomy, die in childhood
atrophy generation, caused by fasciculations mechanical ventilation) Type III lives to
programmed cell death adulthood
- Three types in childhood
adjuvant therapy in patients with neuromuscular RT must be able to recognize acute changes in res-
disease. piratory status and to quickly address respiratory
The role of the respiratory therapist (RT) is decompensation when it occurs. The RT’s responsi-
of central importance in performing diag- bilities include the following:
nostic testing, such as pulmonary function tests, and
providing maintenance therapies, including airway • Spirometry
clearance and respiratory support. Furthermore, the • Overnight sleep studies
2831_Ch17_433-452 13/03/14 3:39 PM Page 436
Standard spirometry may be used in the evalua- Total lung The maximum amount of gas able to
tion of lung volumes and ventilation in children and capacity be contained in the lungs
adolescents (Fig. 17-1) (Table 17-2). The inability to Tidal volume The amount of gas inhaled and ex-
expire fully to residual volume (RV) because of res- haled during normal resting breathing
piratory muscle weakness may result in a decreased Residual The amount of gas remaining in the
forced vital capacity (FVC) and a functional restric- volume lungs after a complete exhalation
tive lung disease. These children have decreased pul-
monary reserve and may be at increased risk for Forced vital The amount of air that can be force-
pulmonary decompensation, especially during res- capacity fully exhaled after a maximum
piratory illnesses. Minimally, an annual assessment inspiration
of pulmonary function should be performed in chil- Maximum The pressure obtained when a
dren with neuromuscular disorders who are old inspiratory patient quickly breathes in fully to
enough to complete the maneuvers because these pressure total lung capacity
tests can provide valuable information about subtle Maximum The pressure obtained when a
progression of respiratory muscle weakness and expiratory patient breathes out quickly and
episodic changes, even in the absence of clinical pressure forcefully to residual volume
symptoms. Establishing baseline spirometry values
by 6 years of age can allow for longitudinal assess-
ment and early interventions when indicated. Meas-
urements of maximal inspiratory pressure (MIP)
and maximal expiratory pressure (MEP) are easily tone, which can be associated with obstructive
performed and can help assess respiratory muscle apneas and hypopneas during sleep (2, 3). Because
strength in children with a neuromuscular disorder. symptoms of early respiratory failure can often be
To perform MIP and MEP, the clinician uses a detected during sleep, an overnight polysomnogra-
handheld device and has the patient breathe in phy (sleep study) can be useful in diagnosing early
quickly and out quickly and forcefully to residual signs of respiratory failure in patients with a neuro-
volume. muscular disorder. Overnight polysomnography
With increasing age, respiratory failure is more should be considered in any child with moderate-
common in individuals with progressive neuromus- to-severe restrictive lung disease; however, the fre-
cular diseases (e.g., DMD). Individuals with DMD, quency at which sleep studies are needed depends on
for example, often develop compromised airway each patient’s clinical condition.
Liters
6
5
Inspiratory
reserve
4
Vital
capacity
Total
Tidal volume 3
lung
capacity (normal breath)
2.5
2
Expiratory
reserve
1
Figure 17-1 Pulmonary Volumes
(Taber’s Cyclopedic Medical Dictionary. Residual volume
F.A. Davis, Philadelphia, 2009, p. 1937; 0
with permission) Time (seconds)
2831_Ch17_433-452 13/03/14 3:39 PM Page 437
be fully understood. Special care should be given There are multiple variants of GBS. The “classic”
to the patient to provide appropriate emotional disorder is known as acute inflammatory demyeli-
support. nating polyradiculoneuropathy. Demyelination refers
to loss of the myelin sheath on the nerve axon
Guillain-Barré Syndrome (Box 17-1). The myelin sheath is essential in the rapid
conduction of nerve impulses through the neuron
Guillain-Barré syndrome (GBS) is a neurological (Fig. 17-2). Patients present with weakness in both
condition that affects peripheral nerves and presents arms and legs, progressing to partial or incomplete
as progressive ascending weakness in both arms and paralysis, known as paresis. Loss of deep tendon
legs and areflexia, or absence of reflexes. Symptoms reflexes also occurs. Progression of symptoms can be
move upward from the arms and legs toward the over the course of several days or can have a
head. It mostly affects motor function, but can also rapid and severe onset, causing respiratory failure in
impair sensation. GBS is the most common cause of 24 to 48 hours. Lumbar puncture shows no signs of
acute flaccid paralysis (relaxed or absent muscular infection.
tone) in children. Another variant of GBS, acute motor axonal neu-
The annual incidence in children is between 0.4 ropathy, was first recognized in China and is strongly
and 1.4 cases per 100,000 children younger than associated with C. jejuni infection. Axons are the part
16 years of age. Incidence in adults is significantly of the nerve cell that transmits electrical impulses
higher, with rates of 1.1 to 2.8 per 100,000 annually. away from the body of a nerve. Acute motor sensory
There is a bimodal peak in incidence in young adults axonal neuropathy is a variant more commonly
and in the elderly. Overall rates range from 1.1 to found in adults and is seen throughout the world.
1.8 per 100,000 (5). This variant tends to be more severe, and recovery
GBS typically presents in previously healthy indi- time can be prolonged. Finally, Miller-Fisher syn-
viduals and often following acute illness with a variety drome is also a demyelinating form of GBS that pres-
of infectious disease agents. It is thought that most ents with descending (starting at the head and
cases of GBS are caused by an atypical peripheral moving toward the arms and legs) paralysis, ataxia
nerve immune response to an infection. It has been (lack of coordination of the limbs), loss of reflexes,
documented following infection with Campylobac- and external ophthalmoplegia. Ophthalmoplegia is
ter jejuni, cytomegalovirus, Mycoplasma pneumonia, the paralysis of any of the muscles involved in the
Haemophilus influenzae, and Epstein-Barr virus. There external movement of the eye (7).
have also been documented cases following immuniza-
tions, but this risk is considered to be very low (6). Clinical Manifestations
Children with GBS typically have no significant his-
Pathophysiology tory of neurological issues. They often have a respi-
The exact cause of GBS is not clear, but several fac- ratory or gastrointestinal illness prior to developing
tors have been identified that may play a role. One
of the most likely causes is related to the develop-
ment of antiganglioside antibodies. Gangliosides Box 17-1 Neuron Basics
are complex molecules that are in nerve cell mem-
branes and are instrumental in recognition of cells The basic cell that makes up all nerves is called the
and cell-to-cell communication. In GBS, antigan- neuron (see Fig. 17-2). Neurons have a large cen-
glioside antibodies bind to peripheral nerves, causing tral body called the soma. The nucleus of the cell
their impaired functioning. In patients who develop is in the soma. Fingerlike projections from the
GBS following infection with C. jejuni, the bacteria cell body are called dendrites. Information is con-
has been shown to express lipo-oligosaccharides that ducted away from the soma along a lengthy pro-
mimic the carbohydrate structure of gangliosides on jection called the axon. The insulation on the axon
the cell. This can produce antiganglioside antibodies is called myelin. Myelin helps the signal conduct
that cause neuropathy, a disease or malfunction of down the axon more efficiently and functions as
the nerves. Additional factors that lead to GBS in- insulation. Ranvier nodes break up the conduction
clude local complement activation, which causes down the axon. In GBS, the myelin is attacked,
nerve cell damage, and an individual patient’s ge- causing disease. Neurons transmit signals between
netic predisposition to developing the disorder. other neurons by releasing chemicals called neuro-
These factors combine to impair nerve conduction transmitters. This exchange occurs at the junction
and can result in weakness, sensory loss, and loss between nerve cells called the synapse. Diseases
of deep tendon reflexes, such as when you hit your such as myasthenia gravis, botulism, and tetanus
knee or ankle tendons and your ankle or knee jerks attack the cell at the synaptic junction.
automatically (6).
2831_Ch17_433-452 13/03/14 3:39 PM Page 439
Node of
Soma Nucleus Ranvier
Synapse
Myelin
Myelin
Axon
Axon
Dendrites
Figure 17-2 Motor Neuron (Taber’s
Cyclopedic Medical Dictionary. F.A. Davis,
Philadelphia, 2009, p. 1574; with permission)
GBS. They may complain of numbness, tingling, or or infection, such as increased white blood cells or
weakness in the arms and legs. Younger children bacteria.
may not be able to walk. This typically precedes res- Electromyography (EMG) and nerve conduction
piratory compromise. Occasionally, presentation is studies are part of the routine workup for GBS. In
more consistent with upper airway obstruction or ill- an EMG, an electrode is used to assess if muscles are
ness. As weakness and paralysis progress, children functioning properly based on electrical activity of a
will develop the following: given muscle. A nerve conduction study tests if there
is nerve damage by stimulating the nerve with small
• Tachypnea
amounts of electricity. These tests can help differen-
• Retractions
tiate between axonal and demyelinating variants of
• Nasal flaring
GBS and are part of the routine workup for children
• Decreased aeration
presenting with acute onset of weakness (8–10).
• Hypoxia
If cranial nerves are affected, swallowing can be- ■ ■ The next morning, the pediatric neurology service
come impaired. This can lead initially to hoarseness, is consulted on William’s case. They recommend a
drooling, and ultimately dehydration. Patients often lumbar puncture, magnetic resonance imaging of the
have difficulty clearing upper airway secretions. As brain and spinal cord, and EMGs. Tests were normal
GBS progresses to respiratory failure, chest radi- except for his EMGs, which were consistent with
ograph would possibly show basal atelectasis and GBS. Stool studies were positive for C. jejuni.
decreased lung volumes. Blood gas findings would Later on that day, William has difficulty swallow-
be consistent with respiratory failure. Decline in res- ing his lunch and starts drooling. His hands and
piratory function from GBS can be tracked by meas- arms get progressively weaker. MIPs and MEPs are
uring MIP, MEP, and FVC measurements at the obtained. His MIP and MEP were −60 cm H2O and
bedside using handheld devices. Progressive de- 50 cm H2O. His FVC was 1.2 L. Based on his de-
creases in these measurements may indicate impend- clining status, plasmapheresis treatments were initi-
ing respiratory failure and can help the health-care ated. At 11:30 p.m., William’s parents call his nurse
provider determine when to escalate care for these to the room because his color doesn’t look right.
patients. Pulse oximetry on room air is 75%. The nurse im-
A lumbar puncture, which provides a sample of mediately puts him on supplemental oxygen and
the fluid surrounding the brain and spinal cord, pages you, the RT on call. You notice that William
known as cerebrospinal fluid (CSF), is the key to is tachypneic to 45 breaths per minute and is drool-
confirming the diagnosis of GBS. If onset of disease ing profusely. MIPs and MEPs at this point are
is rapid, the CSF might not show any changes. How- −20 cm H2O and 35 cm H2O. William’s FVC is 0.6 L.
ever, it is diagnostic of GBS to have an elevated CSF The rapid-response team is called to the room.
protein without any evidence of acute inflammation
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Tetanus
Tetanus is a neurological disease caused by a neuro-
toxin that is produced by the anaerobic bacterium
Clostridium tetani. Tetanus can affect neonates, chil-
dren, and adults. There is no increased risk based on
gender. Because of the widespread use of immuniza-
tions, tetanus rarely occurs in developed countries,
with only 40 or fewer cases reported in the United
States per year since 1999. However, tetanus remains
a major cause of illness and death in the developing
world (18). According to the World Health Organi-
zation, in 2009 there were 9,836 cases of tetanus in
children younger than 5 years old worldwide, with an
estimated 61,000 deaths in that population in 2008.
There were 4,712 reported cases of neonatal tetanus Figure 17-3 Infant With Neonatal Tetanus Displaying
in 2009, with 59,000 estimated deaths in 2008 (19, 20). Risus Sardonicus (Courtesy of World Health Organization)
2831_Ch17_433-452 13/03/14 3:39 PM Page 443
were reported in 2006, with ages of those contracting In all types of botulism, signs of progressive weak-
the disease ranging from 23 to 58 years (18, 27). ness and paralysis start in the face and progress
downward. Signs of respiratory distress typically seen
Pathophysiology in babies, such as grunting, nasal flaring, or retrac-
In infant botulism, affected babies absorb toxin pro- tions, are not seen with botulism because of facial
duced in their intestines when the gut is colonized with muscle paralysis. Instead of appearing anxious owing
C. botulinum. It is thought that colonization with the to impending respiratory failure, patients will present
toxin-producing bacteria occurs because normal gut with emotionless expressions. Airway obstruction
flora has not been well established because of infant can occur as a result of pharyngeal muscle paralysis.
age. Unprocessed honey is the most frequently cited The patient will have inadequate VT values owing to
food associated with infant botulism, but only ac- weakness and paralysis of chest wall muscles, includ-
counts for 20% of the cases (26). The remainder of ing the intercostal muscles. Diaphragmatic paralysis
botulism cases are caused by contaminated soil or can occur. A chest radiograph would show flattened
dust or other contaminated foods. diaphragms, decreased lung volumes, atelectasis, and
In food-borne botulism, illness develops follow- possible evidence of aspiration caused by dysphagia,
ing ingestion of food containing botulinum toxin. which occurs early in the disease. Blood gases values
The toxin is produced in food when C. botulinum would initially show hypercarbia, and as respiratory
thrives in appropriate conditions, including an status decompensates, blood gas values would be
anaerobic environment, low pH, low-salt and -sugar indicative of respiratory failure (26).
content, and in temperatures between 4° and 121°C. Clinical history is very important in making the
Food-borne botulism is frequently associated with diagnosis of botulism. For example, history of eating
ingestion of home-canned foods that were not ap- unprocessed honey or foods preserved by home-
propriately processed (26). canning methods can help lead the physician to a
In wound botulism, wounds are contaminated by diagnosis. To confirm the diagnosis, C. botulinum
C. botulinum spores that germinate and produce should be identified in a patient’s stool sample.
toxin in the anaerobic environment of an abscess. In addition, other causes of paralysis should be
This form of botulism is uncommon in children and ruled out, including GBS, tick-borne infections, and
is associated strongly with intradermal use of black myasthenia gravis (25).
tar heroin (18).
Management and Treatment
Clinical Manifestations The management and treatment of botulism will
Symptoms of botulism can evolve over the course of vary depending on the form.
several days or can have an abrupt onset over the
course of a few hours. In infants, the first symptom BabyBIG
is typically constipation, followed by symptoms that Treatment of infant botulism includes provid-
represent impaired function of the cranial nerves. ing the human-derived antitoxin botulism immune
Babies have difficulty feeding and present with a globulin (BabyBIG) as soon as possible. Use of
weak suck and swallow. They will often lose their BabyBIG has significantly shortened hospital stays,
gag reflex. The infant will develop a weak cry and decreased time on MV, and decreased length of tube
will have decreased movements, loss of head control, feeding time in babies with botulism (25, 28, 29).
and loss of facial expression. In addition, infants
with botulism will have impaired movement of their Antitoxin
extraocular muscles. This can result in ocular palsies, In older children, teens, and young adults, treatment
where the eye cannot move in all directions, and it is includes use of antitoxin as well. The antitoxin can
often associated with ptosis (drooping eyelid). This arrest the progression of paralysis but cannot reverse
progresses to generalized hypotonia and weakness. it. However, because the antitoxin is equine in origin,
Respiratory failure can occur when the diaphragm hypersensitivity reactions can occur, but they are rare.
is affected and becomes paralyzed or when there is
weakness in respiratory musculature (18, 26). Antibiotics
In older children, symptoms start with cranial If needed, medications such as penicillin or metron-
nerve involvement as well. Frequent initial com- idazole should be given to treat wound botulism,
plaints include diplopia (double vision), dysphagia after administration of antitoxin (18, 26).
(difficulty swallowing), dysphonia (difficulty making
sounds), and dysarthria (difficulty speaking clearly). Nutritional Support
Paralysis then progresses downward to affect volun- In all age groups, botulism may impair safe swallow-
tary muscles, which can result in respiratory failure ing. Long-term provision of nutritional support via
(18, 26). enteral tube may be necessary.
2831_Ch17_433-452 13/03/14 3:39 PM Page 445
Mechanical Ventilation
From a pulmonary perspective, long-term Multidisciplinary
Teamwork 17-1
MV is often needed to give the patient time to re- Rehabilitation Teams
cover from the effects of botulism toxin. Appropri-
ate techniques that help with mucociliary clearance IT IS COMMON FOR PATIENTS RECOVERING FROM
can help prevent the development of atelectasis NEUROMUSCULAR DISEASES SUCH AS GBS TO
from mucous plugging. Also important is the pre- REQUIRE INPATIENT REHABILITATION FOLLOW-
vention of aspiration events by using enteral tube ING AN ACUTE-CARE HOSPITALIZATION. In the
feeds and maintenance of nothing by mouth status. rehabilitation environment, the RT works in con-
MV modes would be dependent on the age and con- junction with the medical team, speech therapists,
dition of each patient. For smaller children, pressure occupational therapists, and physical therapists
ventilation is often used. Larger children can often to help the patient return to the functional status
use volume ventilation. Because the patient’s lungs he or she had prior to illness. RTs work with
typically are healthy, the goal of ventilator support speech therapists to strengthen swallow and
is to maintain the condition of the lungs to avoid vocalization using speaking valves in patients
additional complications such as atelectasis or with tracheostomies. Occupational therapists and
ventilator-associated pneumonia. physical therapists work to increase core strength
For infants, treatment with certain antibiotics, in- to support recovery of breathing muscles—key
cluding erythromycin or gentamicin, can increase to improving and maintaining the respiratory sta-
risk for MV and prolong neuromuscular blockade tus of the patient. RTs provide invaluable services
and paralysis. They are never indicated in patients to the medical team regarding a patient’s toler-
with botulism. ance for bronchial hygiene using insufflation-
exsufflation devices and chest physiotherapy, ven-
Course and Prognosis tilator support, and optimal timing for weaning
The mortality rate for botulism prior to the 1940s off chronic MV. The RT also is instrumental in
was 60% to 70%. With current medical practices, educating families about long-term respiratory
overall mortality is now 3% to 5%, with excellent therapies that may be needed for children after
prognosis for full recovery, provided no complica- discharge from inpatient rehabilitation.
tions occur (26). To improve outcomes, medical care
should be provided in an appropriate setting to
avoid complications of long-term immobilization
and ventilator dependence. Following weaning off Pathophysiology
ventilator support, rehabilitation will be needed to With age, patients with DMD gradually lose both
help the patient regain strength that was lost during skeletal and cardiac muscle strength and function.
the illness. Many patients will have full recovery, but Children with DMD appear normal at birth and are
the disease may leave some patients debilitated. often not diagnosed before 3 or 4 years of age, when
Physical and occupational therapy are often needed. gait abnormalities become noticeable and calf mus-
Speech and language pathologists can help with cles may appear to be overdeveloped. Mutations in
swallowing rehabilitation and recovery of speech the gene that produces dystrophin lead to the break-
(26) (Teamwork 17-1). down of muscle fibers that is progressive with time
(33). In addition to skeletal muscle breakdown, pa-
Muscular Dystrophies tients with DMD develop heart disease associated
with dilation of all four chambers of the heart and
Duchenne’s muscular dystrophy (DMD) is the most impairment of left ventricular function. In DMD,
common, lethal, X-linked genetic disease, resulting loss of muscle function in the heart may not occur
in rapidly worsening muscle weakness and a decrease at the same time as skeletal muscle declines (33). For
in muscle mass over time. It occurs almost exclusively instance, patients with DMD may lose their ability
in males who are born of mothers who are asympto- to walk long distances before they exhibit cardiac ab-
matic carriers of the gene mutation. DMD affects 1 normalities. Swallowing abnormalities and scoliosis
in 3,500 newborn males (30). The disease is caused or curvature of the spine can also develop in patients
by mutations in the DMD gene that produces the with DMD (34). Early mortality in DMD is usually
protein dystrophin. Although the gene was identified the result of respiratory and/or cardiac failure.
20 years ago, there is no cure for the disease. There
are other forms of muscular dystrophy, such as limb- Clinical Manifestations
girdle, Becker, congenital, facioscapulohumeral, my- Most patients with DMD become wheelchair bound
otonic, oculopharyngeal, distal, and Emery-Dreifuss by approximately 10 years of age (35). As they age,
muscular dystrophy (Clinical Variations 17-1). patients with DMD are often not aware of the
2831_Ch17_433-452 13/03/14 3:39 PM Page 446
canning. Mom started introducing solids a week tachypneic. Her oxygen saturation is 82% on
ago, but Thomas is primarily breastfed. On exami- room air but increases to 95% on a simple face
nation, Thomas is an appropriately sized baby mask. Her chest radiograph is significant for a
for his age. You notice immediately that his eyelids bell-shaped chest wall and bilateral lower-lobe
appear droopy. Although many health-care providers atelectasis.
are examining him, he does not cry. In fact, his face
• What is in the most likely diagnosis for Tiffany?
looks flat. During his time in the ED, you notice that
What specialist(s) do you think should be
Thomas’s respiratory effort is becoming weaker,
called?
and you note shallow breathing. You place him
• What further tests would be helpful to guide
on an oxygen saturation monitor, and his oxygen
Tiffany’s respiratory management?
saturation is 90%.
• Is she at risk for respiratory failure, and what
• What is the likely cause of Thomas’s would you do if she is?
symptoms? • What should Tiffany’s parents be told about MV?
• What tests would you do next to assess his
■ Case 3: John Barnes
pulmonary status?
John Barnes is 18 years old and has Duchenne’s
• What would be indications for MV?
muscular dystrophy. He started college in the fall
• What would you expect the prognosis to be
and has been feeling acutely short of breath for
for recovery from this illness for Thomas?
the past few days, which precipitates his visit to
■ Case 2: Tiffany Bradley the ED. He has a motorized wheelchair and an
Tiffany Bradley is 3 months old and presents assistant who helps him with his day-to-day activi-
to the ED with mild cyanosis, a weak cry, and ties. He uses a cough-assist device on occasion,
poor oral intake. Tiffany was born full term, and but not on a regular basis. In the ED, he is slightly
her mother has noticed that she has been a cyanotic and short of breath, with an oxygen satu-
poor feeder since coming home from the hospi- ration of 75%. His chest examination is remarkable
tal, with each feeding taking up to 45 minutes. for fine crackles throughout, and he has a gallop
Recently, her oral intake has decreased. Her on heart examination. His chest radiograph shows
mother also has noticed that Tiffany is floppier an enlarged heart, pulmonary edema, and bibasi-
than her previous child, who was born 2 years lar atelectasis.
ago. On examination, Tiffany has poor muscle
• Why do you think John is hypoxic?
tone, but she will smile and follow her mother
• Will oxygen alone treat his hypoxia?
with her eyes. She cannot reach to the midline.
• What else would you initiate to help with John’s
Her tongue appears to have mild fasciculations.
respiratory distress?
She also has poor head control and a pectus ex-
• Are there any cardiovascular tests that may
cavatum but does not appear to be in significant
be useful?
respiratory distress. She is tachycardic but not
Multiple-Choice Questions
1. John is a 7-year-old with DMD who is at the 2. Which of the following neuromuscular diseases
pulmonary clinic for a routine visit. He has can be genetically linked?
complained of being more tired lately, even I. Guillain-Barré syndrome
without additional exertion. He is not com- II. Myasthenia gravis
plaining of any acute symptoms of respiratory III. Tetanus
distress, and his parents say that he has been IV. Botulism
taking naps as soon as he comes home from V. Muscular dystrophy
school most weekdays. What evaluations VI. Spinal muscular atrophy
would you recommend to help understand a. I, II, V, VI
the reason for John’s tiredness? b. V, VI
a. MIP and MEP c. II, V, VI
b. Full pulmonary function test (PFT) d. IV, V, VI
evaluation 3. You are caring for a 12-year-old who is experi-
c. Chest radiograph encing an exacerbation of MG. You come in
d. Polysomnography
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2007;120(6):e1380-e1385. 46. Schroth MK. Special considerations in the respiratory
26. Sobel J. Botulism. Clin Infect Dis. 2005;41:1167-1173. management of spinal muscular atrophy. Pediatrics. 2009;
27. Centers for Disease Control and Prevention. Botulism: 123(suppl 4):S245-S249.
General information. National Center for Zoonotic, 47. Zanoteli E, Maximino JR, Conti RU, Chadi G. Spinal
Vector Borne and Enteric Diseases. http://www.cdc.gov/ muscular atrophy: from animal model to clinical trial.
nczved/divisions/dfbmd/diseases/botulism. Updated Funct Neurol. 2010;25(2):73-79.
November 11, 2010. Accessed January 10, 2013. 48. Montes J, Gordon AM, Pandya S, De Vivo DC, Kaufmann
28. Fox CK, Keet CA, Strober JB. Recent advances in infant P. Clinical outcome measures in spinal muscular atrophy.
botulism. Pediatr Neurol. 2005;32(3):149-154. J Child Neurol. 2009;24(8):968-978.
29. Anderson T, Shah U, Schriener M, Jacobs I. Airway com- 49. Mitchell I. Spinal muscular atrophy type 1: what are the
plications of infant botulism: ten-year experience with 60 ethics and practicality of respiratory support? Paediatr
cases. Otolaryngol Head Neck Surg. 2002;126(3):234-239. Respir Rev. 2006;7(suppl 1):S210-S211
2831_Ch18_453-480 13/03/14 3:38 PM Page 453
Chapter 18
Pediatric Accidents
With Pulmonary
Involvement Elizabeth A. Hunt, MD, MPH, PhD
Deeraj Goswami, MD
453
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Chapter Objectives
After reading this chapter, you will be able to:
1. Differentiate between wet and dry drowning and how they present.
2. List the three major therapies for negative pressure pulmonary edema.
3. Understand how to initiate and titrate positive end expiratory pressure when concerned about pulmonary
edema.
4. Discuss the differences in therapy between routine acute respiratory distress syndrome (ARDS) and
near-drowning–induced ARDS
5. Discuss the symptoms that would make an elective intubation indicated, even in a seemingly stable
burn patient.
6. List the factors that make inhalation injury more likely in burn patients.
7. Determine when a hyperbaric chamber should be considered after carbon monoxide poisoning.
8. Know the treatment of the two major systemic complications of inhalation injury: carbon monoxide and
cyanide poisoning.
9. Discuss how behavior and development are important for aspiration risk.
10. Discuss the difference between a partial and complete foreign body obstruction and how to treat each.
11. Discuss the differences and similarities between a hydrocarbon and lipoid aspiration.
12. List the therapies and effects for the treatment of gastric and oropharyngeal secretion aspiration.
■■ John Smith are direct effects to the airway or lung tissues. Acci-
dents with pulmonary involvement include near-
drowning, burn injuries, and aspiration. Each of
You are working in the pediatric intensive care unit
these injuries has subcategories that affect the patho-
(PICU) during the summer when one of your col-
logical severity and clinical manifestations and
leagues calls and gives you an update about John
determine the method and extent of treatment.
Smith, an 8-year-old patient being transferred from
the general pediatric floor to the PICU. John suffered
a near-drowning in a local pool. It was estimated that Near-Drowning
he was submerged underwater for 2 to 3 minutes.
Drowning is the leading cause of unintentional in-
He required rescue breaths but no chest compres-
jury deaths for children aged 1 to 4 years and the
sions, and he coughed up large amounts of water in
third most common cause in children aged 5 to
the field. John was brought into the pediatric emer-
9 years. Males are almost four times more likely to
gency department (ED) looking well and actively try-
die from drowning than are females, and African
ing to explain what happened.
Americans are 1.2 times more likely to die than Cau-
casian children of the same age (1). Furthermore, for
every fatal drowning, four children have to visit an
U
nintentional injuries are the leading cause emergency room for medical therapy as a result of
of death in children aged 1 to 15 years (1). near-drownings. Lack of supervision and lack of ed-
They can also be a major source of pul- ucation (regarding water safety and swimming les-
monary morbidity and long-term sequelae if there sons) are thought to be the primary factors leading
2831_Ch18_453-480 13/03/14 3:38 PM Page 455
release increasing heart rate and raising systemic vas- immunological cells living along the respiratory
cular pressure, thus increasing oxygen demand of the track. The aspiration that occurs in many near-
left ventricle. Simultaneously, pulmonary vascular re- drownings overcomes these defenses and infects
sistance increases, thus increasing the oxygen demand the lung with organisms from the water or the gas-
of the right ventricle. In this setting, oxygen delivery trointestinal (GI) track.
is minimal because no air is entering the lung, and The published incidence of aspiration pneumonia
heart work is increased because the systemic pressure in near-drowning victims has varied in studies from
and pulmonary resistance are higher. Overall, more 0% to more than 50% (11–13). Therefore, it is diffi-
blood flow enters the lung, but there is very high re- cult to know the extent of this problem in this patient
sistance to that blood exiting the heart and lung. population. Anecdotally, the severity of the drown-
The resistance of blood leaving the lungs essen- ing and the amount aspirated (infectious load) is
tially causes a backup and significantly increases the thought to lead to a higher risk of pneumonia, but
hydrostatic pressure in the vessel. The blood in the no studies have proven this. The symptoms of pneu-
lung is under such high hydrostatic pressure that fluid monia can be subtle and similar to numerous other
can begin to leak into the pulmonary parenchyma pathological problems and may cause the lack of
and cause cardiac-induced pulmonary edema. Clini- these studies.
cians should be aware that the effects of both types
of edema can either be seen immediately or have a Acute Respiratory Distress Syndrome
temporal delay. This delay is called secondary drown- Discussed in detail in Chapter 15, ARDS is a pri-
ing, and it can occur up to 24 hours after the initial mary definition that allows the medical community
event and be seen in 5% to 10% of near-drowning to categorize patients. Near-drowning is one of the
cases (8, 9). many causes of ARDS. The definition of ARDS is
as follows:
Surfactant Dysfunction and Atelectasis
• Acute onset of symptoms
Surfactant is a chemically complex agent whose
• Bilateral infiltrates on chest radiograph
main function is to stabilize the air-liquid interface
• No evidence of left atrial hypertension, such as
of the alveoli and bronchioles and to lower surface
a pulmonary capillary wedge pressure less than
tension. Lower alveolar surface tension improves
18 mm Hg, which would suggest a cardiac
lung compliance, prevents alveolar collapse, and re-
cause for the infiltrates
duces work of breathing (WOB).
• A defined degree of hypoxia
The severity of a near-drowning does not always
correlate with the potential for atelectasis. The type Near-drowning primarily causes direct lung injury
of water and a wet drowning can affect surfactant either by infection or disruption of the alveolar-
deactivation, thereby increasing the likelihood of capillary membrane. This type of ARDS may have
respiratory complications. Intubation can also affect worse outcomes and is a major cause of morbidity
the symptoms that are seen. Aspiration of freshwa- in pediatric near-drowning patients (14).
ter, pool water with chlorine included, or salt water The disruption of the alveolar capillary mem-
will cause surfactant dysfunction. Freshwater can in- brane induces proinflammatory events that start
activate surfactant on contact, and both salt water the cycle and is called the exudative phase of
and freshwater can cause fluid shifts that further ARDS. Inflammatory cells invade the alveolar
cause surfactant breakdown (10). space, and fluid and proteins migrate across
the barrier and further pull fluid in by osmosis
Aspiration Pneumonia (Fig. 18-2). This leads to poor compliance and
Lung infections after near-drowning can occur pri- poor oxygen exchange and the need for increased
marily because of aspiration of contaminated respiratory support. Positive-pressure ventilation
water or gastric contents into the lungs. Pneumo- and lung stretch can further encourage the release
nia can be a significant source of morbidity in these of inflammatory cytokines, and mechanical venti-
patients, and care must be taken to recognize lation (MV) on its own can cause lung injury, even
risk and symptoms so that early treatment can be in a healthy patient.
initiated. The fibroproliferative stage of ARDS follows the
The primary pathophysiology of pneumonia is exudative phase after the acute inflammation has
the introduction of bacteria or other organisms stopped. Chronic inflammation can increase lung
into the lung. The body has evolved to have nu- dead space, cause pulmonary hypertension, and scar
merous defense mechanisms to prevent this from the alveolar capillary membrane. The recovery
occurring, including hairs to trap organisms in the phase begins when that membrane begins to heal
nose, small cilia that brush sputum and organisms and once again allows no movement of proteins
out of the respiratory track, and a large number of across it (15).
2831_Ch18_453-480 13/03/14 3:38 PM Page 457
Sloughing
Bronchiole of bronchial
epithelium
Alveolar
Surfactant layer air space
Neutrophil
Alveolar
Red cell
macrophage
Protein-rich
Type I cell edema fluid
Surfactant Necrotic
layer type I cell
Fibroblast
Type II cell
decided by a more senior clinician that the HR and Management and Treatment
RR were elevated beyond normal, and despite look-
The lung damage from pulmonary edema in a near-
ing otherwise healthy, John warranted admission to
drowning victim occurs well before a medical
the ward for further observation. Just prior to trans-
provider can begin therapy. There are a few key
fer, 3 hours after presentation, John started to have
strategies that will help reduce and stop the damage
occasional desaturations to 92% and was placed on
that has already occurred:
1-L nasal cannula and transferred to the floor. On
the floor, over a several-hour period, John had wors- • Early initiation of positive pressure
ening and persistent desaturations requiring progres- • PEEP
sive escalation of support to 60% oxygen by face • Overall fluid balance
mask. The PICU response team (you are a team
The earlier these therapies are started, the more
member) was called to the floor to evaluate the pa-
likely a patient will have a full recovery.
tient. You review the ABG values for the patient from
when he was in the ED and notice that the numbers Early Initiation of Positive Pressure
individually are relatively unremarkable. However, you
Intubation is the most common way to initi-
have a concern that the CO2 was slightly elevated
ate positive pressure in near-drowning patients. A
despite there being a significant amount of tachyp-
possible alternative is NIPPV. This supports respi-
nea (i.e., you would have been expecting a respira-
ratory effort while avoiding the possible complica-
tory alkalosis). You suspect he was already showing
tions of intubation. Adult data suggest that this
signs of lung impairment at that time. You are very
may reduce mortality and morbidity and length of
happy he was admitted and that you now have been
hospital stay, but its use in children is still ques-
called to transition him to a higher level of care. You
tioned by some, despite a potential benefit in a sig-
note that John now is frequently coughing and has
nificant reduction in sedation needs (16, 17). One
tachypnea and nasal flaring, in addition to the in-
of the major downfalls is that the airway is not se-
creasing oxygen requirement, all of which is consis-
cure, leading to increased gastric distention as well
tent with possible aspiration or pulmonary edema
as increased risk of gastric secretion aspiration and
(i.e., delayed symptoms related to the near-drowning
continued decompensation. Furthermore, it can be
event).
difficult to achieve pressure high enough to ade-
You assist in transporting John to the PICU im-
quately ventilate and oxygenate a patient with this
mediately to manage his respiratory failure with the
disease process. Of note, teams may tend to escalate
goal of starting noninvasive positive-pressure venti-
the settings on NIPPV when it initially works, but
lation (NIPPV) to assist with oxygenation, most
it becomes less effective over time with worsening
likely continuous positive airway pressure (CPAP).
lung disease. Whereas some titration of pressure
Upon arrival in the PICU, he is now in worsening
may be warranted, it needs to be watched closely
respiratory distress with oxygen saturations in the
so that a child isn’t on both very high NIPPV set-
high 80s on the 100% non-rebreather used for
tings as well as high concentrations of oxygen, such
transport, with moderate-to-severe retractions. The
that the child is at a high risk of rapidly desaturat-
decision is made to intubate John immediately. He
ing during intubation attempts. This is even more
requires bag-mask ventilation (BMV) to maintain
dangerous when the child is also hemodynamically
saturations while medications and supplies are
unstable. Clinicians may do well to remember the
prepared for intubation. The saturations are ap-
mantra that “things are likely to get worse before
proximately 88% with BMV, so you discuss a plan
they get better,” and opt for early intubation in a
with the physician and agree to increase the posi-
child who requires escalating support.
tive end expiratory pressure (PEEP) on the resusci-
tation bag to 10 cm H2O and use a slightly longer PEEP
inspiratory time. The saturations subsequently in-
crease to 95%. Because there is good chest PEEP is used to stent airways open and can also be
movement with BMV, the sedation and paralysis used to increase the pressure of the alveoli in an at-
medications are administered, and the RT notices tempt to keep fluid from leaking out of the capillary
improved compliance of the lung, with further im- bed. Essentially, the gradient that is causing the fluid
provement in the saturations as they increase to leakage is either reduced or overcome. Fluid could
99%. The intubation is completed with only a mild potentially be “pushed” back into the capillary bed
desaturation to 92%, likely secondary to excellent if the gradient is overcome, which may further im-
preoxygenation. Once the tube is in place, frothy prove lung function (18). The starting PEEP is usu-
serosanguineous fluid begins to come out of ally 5 but can reach up to 12 and beyond in severe
the tube. lung disease. The concern is usually overdistension
of the lungs, and this can be checked by CXR. Lung
2831_Ch18_453-480 13/03/14 3:38 PM Page 459
■ ■ John’s CXR showed right lower lobe and right the course of a patient with aspiration pneumonia after
middle lobe collapse. CPT and humidified saline a near-drowning event. However, there are no appar-
therapy were initiated. The ventilator settings were ent studies directly looking at DNase and its use in
increased to a PIP of 20 and PEEP of 7, with im- pneumonias in near-drowning patients.
provement on subsequent CXR. You notice on your
next shift that John began to have increased thick
■ ■ John was started on antibiotics, his fever abated,
yellow secretions, and the nurse stated the he now
and he showed an improvement in respiratory symp-
had a new-onset fever. A CXR and an endotracheal
toms over the next 12 hours. The endotracheal cul-
culture were obtained; they showed a new right-
ture grew out streptococcus pneumonia, and
sided consolidation, an endotracheal culture with
ceftriaxone was continued for a 7-day course. John
many polymorphic nuclear cells (neutrophils), and a
had a deteriorating course the following 12 hours, in-
Gram stain showing gram–positive cocci.
cluding tachypnea, increased oxygen demands, in-
creased ventilator settings, and decreased exhaled
VT values on the ventilator. CXR in the morning
showed bilateral infiltrates. John’s ventilator settings
Treatments for Aspiration Pneumonia
were PIP of 30 cm H2O, PEEP of 8 cm H2O, RR of
Treatment for aspiration pneumonia includes alve- 24 breaths per minute, fractional concentration of in-
olar stabilization and bronchial hygiene (discussed spired oxygen (FIO2) of 0.90 because of recurrent de-
in the previous section), as well as treating the infec- saturations, and his ABG values were pH 7.21, partial
tious causes and managing consolidation. pressure of oxygen (PaO2) of 62 mm Hg, partial pres-
sure of carbon dioxide (PaCO2) of 60 mm Hg.
Antibiotics
Antibiotics are a mainstay for the treatment of any
type of pneumonia. However, the variability of the or-
ganisms that can potentially cause pneumonia in near- Treatments for ARDS
drowning victims can make it challenging to determine The incidence of ARDS in near-drowning victims is
which antibiotic to use. The fluid that is aspirated difficult to ascertain from studies. Most near-drown-
could be gastric contents or polluted freshwater, salt ing victims do not come to the ED, and the reported
water, pond scum, and so forth, all of which vary in data are mostly from the subset of patients admitted
terms of the organisms growing in them. Therefore, to the ICU. Drowning is a relatively rare cause of
when a near-drowning patient develops a clinical pic- ARDS in the ICU, but the percentage of near-
ture suggesting pneumonia, it is important to initiate drowning patients admitted to the ICU who are ul-
broad-spectrum antibiotics that will cover anaerobes timately diagnosed with ARDS varies from less than
and aerobes as well as gram-negative and gram-positive 5% to as high as 50% (27–29).
organisms. There are no data on which antibiotic is Chapter 15 presented a full discussion of ARDS;
best, but those commonly used include piperacillin/ thus, this section specifically discusses the therapies
tazobactam, meropenem, cefepime, vancomycin, cef- in relation to near-drowning.
triaxone, and clindamycin, among others.
Prophylactic antibiotics were widely used until Ventilator Strategy
concern about resistant infections grew in the late There are no specific data on the use of venti-
1990s. Multiple studies have shown that prophylac- lator strategies for ARDS induced by near-drowning.
tic antibiotics neither prevent infections nor improve High PEEP and low VT ventilation of 6 mL/kg are
morbidity or mortality (5, 26). Some clinicians will considered optimal for treatment of ARDS patients.
still advocate the use of antibiotics if the body of Permissive hypercapnia and hypoxia to decrease lung
water is considered heavily polluted. However, in the injury from lung overdistension are also advocated.
case of empirical coverage, if no bacterial growth is High-frequency oscillator ventilation and airway
noted at 48 hours, it would be prudent to consider pressure release ventilation have been discussed as
stopping antibiotics at that time. possible treatments, but neither has been proven to
be better for ARDS than the conventional ventilator.
DNase The mechanism of action is thought to be decreased
The consolidation seen in pneumonia is a com- stretch leading to less inflammation and less chronic
bination of dividing and dead bacteria and attacking lung damage.
and dead inflammatory cells. These cells can cause
plugging of small airways, especially in patients who Corticosteroids
are intubated and unable to cough on their own. The There are some specific data on steroid use in near-
breaking up of the plugs allows for the improvement drowning patients. As with ARDS from any cause,
in symptoms; thus, DNase might theoretically improve there is also similar controversy about its use.
2831_Ch18_453-480 13/03/14 3:38 PM Page 461
Table 18-1 Variables Associated With Death or Poor Neurological Outcomes in Near-Drowning
Location of Drowning ED PICU
lung function can be harmful for a heart that has is correlated with the intensity of the heat; lung
been damaged and whose function is poor. These damage and systemic complications are dependent
complicated factors have to be considered individ- on the substances ignited during the fire (48).
ually, and often a compromise is made depending The pathology and clinical signs and symptoms
on the patient’s overall medical condition (Special vary based on the cause of injury, but the course of
Populations 18-1). healing and prognosis are similar. Each type of in-
halational injury is described separately, but course
Inhalation Injuries and prognosis are compiled together at the end of
the section.
Inhalation injuries are not a common burn finding
in children. Burns from hot water and liquids are the Upper Airway Injury
most common types of burns seen in children, and
these are the least likely to cause inhalation injuries. Upper airway burns can be very subtle in their pres-
Steam from these substances is the only exception, entation. A child can be talking and looking well;
and inhalation injuries from steam can be very se- however, the development of respiratory distress can
vere. Thirty percent of children with burns will have be insidious and life threatening. It is important for
concomitant inhalation injuries. The likelihood in- RTs to recognize these subtle signs because early
creases if the victims are exposed to an actual fire therapy could be lifesaving.
and if this fire is in an enclosed space (47).
There are several major concerns with inhalation Pathophysiology
injury. The first two are upper airway injury and The pathophysiology of upper airway damage is di-
lung damage from the heat and the burning chem- rect thermal injury. The heat in enclosed spaces can
icals and gases that are inhaled. The third is the sys- reach up to 1,000°F (49). The upper airway has
temic complications that occur from the absorption adapted and become very efficient at heat transfer.
of these chemicals and gases. Upper airway injury This prevents injuries to the lung but can cause se-
vere injuries to the nasopharynx and oropharynx.
Heat transfer causes tissue damage and resulting in-
● Special Populations 18-1
flammation and edema. This could potentially cause
Permissive Hypercapnia or Not? airway obstruction and death.
Prolonged hypoxia from a near-drowning event can Clinical Manifestations
cause pulmonary and systemic pathology. The most The airway obstruction in burn victims is similar to
severe of these would be a cardiac arrest in a child, that from any other cause. The obstruction in this
which is causing multisystem organ failure. The heart case is from airway edema and can occur very
function can initially be poor, and the potential for re- quickly. Actual symptoms are very late findings, and
current cardiac arrest would be high. It would be advanced airway management must occur quickly to
likely that lung damage would be severe in this type prevent potential respiratory arrest. Clinical signs in-
of patient as well, and the use of lower pressures clude the following:
could prevent further lung injury. ARDS ventilation
strategies, such as permissive hypercapnia, would be • Singed nares
beneficial for the lung but could potentiate rearrest in • Soot along mouth or nose
the child. Acidosis in a poorly functioning heart may • Facial burns
be the added factor that causes rearrest. This may • Stridor
be a case where the medical team will not allow per- • Dyspnea
missive hypercapnia and acidosis. • Increased WOB/retractions
• Cyanosis
2831_Ch18_453-480 13/03/14 3:38 PM Page 463
Management and Treatment half-life (how long until half the drug is metabolized
by the body) is very long (36 to 48 hours), and the
Airway and respiratory management of patients with
onset of action is thought to be around 4 to 6 hours.
smoke inhalation is a mainstay of therapy. Assess-
Whereas racemic epinephrine is used to acutely im-
ment of respiratory distress and airway stabilization,
prove mild symptoms of airway edema, dexametha-
followed by management of upper airway edema, is
sone is used to decrease any further edema formation.
essential within the first several hours of therapy.
There are also no primary studies of its use for airway
Intubation burns, but some experts advocate its use under certain
conditions (55).
Early intubation is essential for children who
have a smoke-inhalation injury. There is support in
the literature that delaying intubation can lead to in- Direct Lung Injury
creased difficulty with a later attempt (50). Therefore,
Thermal injuries do not typically affect parenchymal
it is essential that intubation occur quickly in patients
tissue because of the excellent heat dissipation by the
with any of the clinical signs noted for upper airway
upper airway. Any particle larger than 10 m will get
injury. The ETT should be cuffed and age appropri-
trapped in the upper airway; particles between 3 m
ate. The risk of airway complications is increased
and 10 m will be deposited in the proximal bronchi-
with cuffed ETTs, but this does not outweigh the po-
oles; and particles smaller than 3 m will find them-
tential risks of respiratory compromise secondary to
selves in the distal airway and alveoli (Fig.18-3) (56).
leaks or the need for a tube exchange (51, 52). The
The burning of plastics and other compounds, how-
most severe complication of a cuffed tube is tracheal
ever, can lead to multiple products that can cause
stenosis, and this can require further surgical care to
severe damage to all parts of the airway, including
correct in the future. The intubation should be per-
the lungs (48, 57). The extent of damage can be cor-
formed by the most experienced airway technician
related with the components in the smoke, the length
because it can be technically difficult and may require
of exposure, and the patient’s minute ventilation (57).
the use of advanced equipment (e.g., video laryngo-
scope, fiber-optic laryngoscope). Lower-airway in- Pathophysiology
jury also is likely in these cases, and the patient may
The pathophysiology of lung injury from smoke in-
need significant amounts of ventilatory support.
halation is multifactorial but is initiated by mucosal
A full evaluation of the airway should be com-
and cell injury. Other important components include
pleted early, either after the intubation or before, de-
surfactant destruction, alveolar capillary membrane
pending on the risks of the patient. This could include
damage, and increased blood flow (58, 59). The pres-
a nasopharyngeal scope and/or bronchoscopy if there
ence of body burns and concomitant fluid manage-
is concern about vocal cord or lower airway injury.
ment potentiates further lung damage and increases
Intubation allows for adequate ventilation and
the likelihood of pulmonary edema and ARDS. This
oxygenation despite swelling that would inhibit air
requires increased respiratory support and further
exchange.
damages the lung parenchyma.
Racemic Epinephrine Mucosal and cell injury will lead to edema forma-
Racemic epinephrine is an aerosolized version tion within the first 24 hours. The initial injury will
of epinephrine that is typically used in patients with cause an immediate release of inflammatory cy-
croup, but it has also been used in patients suffering tokines, which will increase blood flow and weaken
burns, postextubation obstruction, and bronchiolitis. the already-damaged alveolar capillary membrane.
The primary mechanism of action is an alpha effect
and mucosal vasoconstriction that decreases edema
and a beta effect of muscle relaxation that further in-
creases airway diameter. This allows better airflow
through swollen areas and improved respiratory Nose: ⬎ 10 m
Mouth: ⬎ 15 m
symptoms. There are no primary studies looking at
its use in burn patients, but multiple small studies dis-
cuss and advocate its use in patients with mild respi-
5-10 m
ratory symptoms from inhalation injuries (53, 54). (first 6 generations)
Dexamethasone
Dexamethasone is a steroid whose anti-inflammatory 2-5 m
effects are helpful with airway edema. It is also pri- 0.8-3.0 m
marily used for croup and postextubation obstruction
but is not as fast acting as racemic epinephrine. The Figure 18-3 Particle Deposition in the Airway
2831_Ch18_453-480 13/03/14 3:38 PM Page 464
Infectious fighting cells will cross the barrier along and other modes of physiotherapy may take prece-
with fluid in an attempt to clear the dead cells and dence. Early ambulation and allowing the patient to
protect the body from secondary infections. The ep- sit in a chair are possibilities. These decrease the like-
ithelial layer will shed and hemorrhage, leading to lihood of muscle underuse and improve pulmonary
clumps of debris sitting in the tracheobronchial tree. physiotherapy by ventilating areas of the lung that
These areas are filled with inflammatory cells and cy- are partially collapsed (62).
tokines and are also prime breeding areas for bacte-
ria (60). These clumps of debris can continue to Bronchodilators
evolve and form fibrin-like casts that can severely af- The primary bronchodilator used in patients
fect gas exchange and make it very difficult to oxy- with smoke inhalation is albuterol. Albuterol is a 2-
genate and ventilate a patient, even on the highest agonist and is often used for asthma to dilate con-
settings (61). stricted areas of the bronchial tree to allow for better
airflow out of the lung. The effect it has on airway
Clinical Manifestations resistance can be substantial and potentially can
The manifestations of direct lung injury are very sim- allow for a significant decrease in the MV required
ilar to those of upper airway injury. The assumption for a burn patient. The second major effect is a de-
is anyone with upper airway inhalation injury will crease in inflammation. There are animal models
also have direct lung injury. Clinical signs include that show that albuterol decreases the production of
the following: certain cytokines from the body, many of which ini-
tiate the process of alveolar-capillary leak, including
• Singed nares
TNF-␣ and leukotrienes (63, 64).
• Soot along mouth or nose
There are currently no prospective trials on al-
• Carbonaceous secretions
buterol or any 2-agonist in humans with inhalation
• Dyspnea
injuries. There are some animal data that showed an
• Hypoxia
improvement in peak and plateau airway pressures as
• Retractions/respiratory distress
well as the PaO2/FIO2 ratio, and a similar study was
The primary means of diagnosis is bronchoscopy completed with tiotropium, a muscarinic antagonist,
and it is advocated by the majority of burn centers. which showed similar results (65, 66). A pilot study is
Fiber-optic bronchoscopes are available in diameters under way at Shriners Hospitals for Children at the
as small as 2.8 mm, allowing endoscopic inspection University of California at Davis to test the efficacy
of patients with ETTs as small as 3.5 cm. of albuterol in children with inhalation injuries (67).
Management and Treatment Inhaled Nitric Oxide
Respiratory care for inhalation injury focuses on The primary clinical use of iNO is as a pulmonary va-
bronchial hygiene and minimizing the effects of air- sodilator for neonates with persistent pulmonary hy-
way edema on oxygenation and ventilation. Al- pertension. The vasodilatation of the pulmonary
though none of these therapies will reverse airway artery allows better blood flow and improved oxy-
damage or speed healing of airway cells, they will genation of the blood. The pathophysiology of in-
stabilize the respiratory system to allow the time nec- halation injury can severely affect gas exchange at the
essary for pulmonary recovery. alveolar level. Inhaled nitric oxide has been used in
burn patients to attempt to improve the gas exchange
Chest Physiotherapy and shunting that can frequently occur in these pa-
CPT is probably the most-used treatment for pa- tients. There has been one small retrospective study
tients with lung inhalation injury. Pain, MV, and the in children with inhalation injury and iNO (68). The
extreme hazard of accidental extubation can make study showed improvement in the oxygenation of
its use difficult, but the benefits far outweigh the children but was not large enough to show an effect
risks. CPT has been shown to effectively remove on morbidity or mortality.
secretions in a variety of patients. Victims of inhala-
tion injury have a large number of thick secretions, Nebulized Heparin and Other Anticoagulants
especially after the sloughing of dead epithelial cells. Heparin’s primary use is as a systemic anticoagulant
CPT is thought to increase the likelihood of self- to inhibit clot formation. Clots and fibrin casts are
removal or suctioning of airway secretions, making major inhibitors of ventilation and oxygen exchange,
it less likely that distal airway bronchioles will be and they are a primary component of the lung injury
plugged and decreasing the nidus for infections. in smoke inhalation. These casts can be extremely
Grafts and body-surface injuries can complicate difficult to treat because they are unlikely to be re-
CPT in patients with burns. These areas should be moved by suctioning, CPT, and other forms of
avoided as much as possible when percussion is used, bronchial hygiene.
2831_Ch18_453-480 13/03/14 3:38 PM Page 465
Clinical Variations 18-1 during this process further damage these organs,
leading to their failure. The more organs affected,
Cyanide Poisoning the higher the morbidity and mortality rate for the
patient (Teamwork 18-1).
It is common that burn patients will be taken to the Chronic complications are rare in child victims of
closest ED for stabilization. It is important to know the inhalation injury. There is concern, however, for
subtle signs of cyanide poisoning because it is easily possible decreased exercise endurance and cardiac
treated but just as easily missed. Clinical signs include limitation during maximal exercise (54, 80). The
the following: severity of the complications correlate with the
• Unusually red or pink skin (oxygen not being severity of inhalation injury. Overall, most children
removed from hemoglobin) do well with minimal, if any, noticeable effects.
• Headache, nausea, altered mental status (early
signs of hypoxia) Aspiration
• Lactic acidosis despite adequate oxygenation
Quick therapy is lifesaving, and patients die because The study of aspiration in children is complicated by
of delayed diagnosis. the different causes and variability in treatment.
Simply, aspiration is defined as material passing the
vocal cords and into the tracheobronchial tree. The
material can be volatile, solids, or oral secretions.
this time is better able to evaluate the extent of injury Because the epidemiology, pathophysiology, man-
and the morbidity and mortality risks for the victim. agement, and prognosis are so different for the var-
Thirty percent of burn patients will also have ious causes of aspiration, they will be discussed in
smoke-inhalation injuries. The morbidity and mor- separate sections below.
tality rate is between 3% and 10% for all burns and Lung injury is the common component for any
increases to 20% to 30% with concomitant smoke in- type of aspiration and leads to respiratory distress
halation. Pediatric mortality is directly dependent on and decompensation. RTs must be able to identify
total body surface area (TBSA) burned. Patients different types of aspiration since treatment for one
with a 73% TBSA burn have a 10% burn-associated could potentially harm a patient that is affected by
predicted mortality, but the mortality rate increases another.
dramatically to 50% at the same TBSA when the vic-
tim has a smoke-inhalation injury as well (47, 78).
Calculating the percentage of burns is based on
patient age and thickness of the burns. A common Sometimes You
Teamwork 18-1
formula used to calculate the percentage of skin Have to Be a Mediator
burned is the rule of nines. When using this calcula-
tion for adults, the head represents 9%, each upper P ATIENTS WITH MULTIPLE INJURIES AND
extremity 9%, the back of the trunk 18%, the front MEDICAL CONCERNS CAN HAVE A NUMBER
of the trunk 18%, each lower extremity 18%, and the OF DIFFERENT SURGICAL AND MEDICAL
perineum the last 1%. In children, percentage of TEAMS TAKING CARE OF THEM . For instance,
burn calculation should take into consideration the our burn patient is a trauma patient and a PICU
age of the child because body proportions are differ- patient. The two teams are helping take care of
ent from those of adults. The rule of nines has been the child, and sometimes the goals of therapy can
adapted for children to include the head as 18% and contradict each other. The patient may have a
each lower extremity as 13.5%, with the rest of the small pneumothorax that would benefit from
calculations the same as adults. The Berkow formula 100% oxygen, but this could be harmful to the
was designed as a way to more accurately calculate lungs and the rest of the body. The teams may
TBSA burns in children and has percentages based express their ideas to you because you are at the
on age (79). bedside and the one making ventilator changes.
Multisystem organ failure is a common finding It is important to bring the team together rather
in severe burns. The cause can be from the primary than becoming frustrated with contradicting or-
burn and lung injury leading to ARDS, rhabdomy- ders. There are strategies that may help:
olysis (skeletal muscle destruction, causing acute • Stating the objective reasons why you believe
renal failure), and sepsis, among many others. Car- making changes could be harmful
bon monoxide and cyanide poisoning can also • Calling other members of your team to the
cause multisystem organ failure. When the end or- bedside to have a group discussion and then
gans are starved for oxygen, the body begins make a decision together
anaerobic metabolism. The acids that are made
2831_Ch18_453-480 13/03/14 3:38 PM Page 468
Clinical Manifestations
The clinical manifestations of upper versus lower
FBAO may differ and may help clinicians distin-
guish which portion of the airway is affected. Quick
assessment is necessary depending on the size of the
object aspirated and the degree of airway obstruc-
tion to reverse symptoms and prevent complete air-
way obstruction.
attempt to swallow material they shouldn’t swallow, pneumonia. The two mainstays for treating lipoid
and anatomical and physiological development make pneumonia are antibiotics and steroids (112–115).
aspiration likely. There are important differences, There is a case report of using intravenous im-
however, and these can affect clinical manifestations munoglobulin, but its use is not as widely reported
and therapy. as steroids and antibiotics (115). This treatment is
The first of these differences is the taste and acid- used primarily during the initial presentation; there
ity of the chemicals. Oils and fats either have no is no evidence that early treatment or any treatment
taste or taste good to children. Hydrocarbons are improves the course of the disease.
usually fairly noxious, and there will be an imme-
diate negative response from the child who ingests Course and Prognosis
them. Therefore, with lipoids, it can be more diffi- The outcome and prognosis of lipoid aspiration are
cult to obtain a history of aspiration, and more of favorable, and patients are likely to make a com-
the substance could be aspirated. Oils can diminish plete recovery. However, there are cases of acute de-
or inhibit the gag reflex, again making the determi- compensation and death. The course is indolent,
nation of aspiration difficult (110). Parents give the and it can take years for patients to make a full re-
lipoid product for therapy and may not associate a covery. Some data indicate that the chronic inflam-
medication as a possible cause for respiratory fail- mation from the indolent course can cause fibrosis
ure. This increases the probability of subsequent and lung insufficiency (116). This has led to right
events and might not be discussed as a potential heart failure in some adult patients, but no long-
cause of respiratory distress by the parent. term outcome studies have been completed with
The primary cause of lung injury in lipoid aspira- children (117).
tion is direct inflammation. The oils cause a cytokine
release, and macrophages and other inflammatory
cells are released into the lung parenchyma. The sub- Oral Secretions
sequent inflammatory response is similar to that seen Secretions can include both oral and gastric secre-
with hydrocarbons. The difference is the inflamma- tions. The section on oral secretions includes the as-
tory response can be blunted, and symptoms can be piration of formula and other material in children
acute or occur years after initial exposure. Lipoids with oral motor pathology. The section on gastric
also stay in the alveolar space, which can further secretions will focus on reflux and the effect of gas-
delay and prolong symptoms. Lipoid aspiration does tric contents on the lung parenchyma.
have an effect on the mucociliary response of the tra- The aspiration of oropharyngeal secretions has be-
cheobronchial tree. This inhibits the expectoration of come an increasing problem in the pediatric popula-
the lipoid and allows persistent inflammation (111). tion. Dysfunctional swallowing is a broad term that
Clinical Manifestations describes abnormalities in swallowing or managing
oropharyngeal secretions; it is a well-recognized
There can be repeated lipoid aspirations before a cause of aspiration in children and can be caused by
child shows any respiratory symptoms. History is ex- prematurity, CNS abnormalities, and craniofacial
tremely important and is usually the key component syndromes (118, 119). Aspiration of oropharyngeal
in the diagnosis of a lipoid aspiration. There are no secretions causes lung damage and increases the like-
clinical symptoms or radiological studies that sug- lihood of pneumonias. Furthermore, the major causes
gest a lipoid aspiration, and the symptoms are simi- of dysfunctional swallowing are not temporary in na-
lar to many of the other pathological conditions that ture, thus leading to recurrent aspiration, lung dam-
cause respiratory distress: age, and pneumonias (Special Populations 18-2).
• Tachypnea Data suggest that oropharyngeal aspiration is the
• Persistent cough most common cause of recurrent pneumonias in chil-
• Cyanosis/hypoxia dren and the cause of 8% of all pneumonias seen in
• Recurrent pneumonias the hospital (120). This number is likely to increase
• Lipid-laden macrophages on bronchoalveolar because there is a link between neurologically im-
lavage constitute a definitive diagnosis paired children and pneumonias. The number of neu-
rologically disabled patients is increasing, primarily
Management and Treatment as a result of improvement in neonatal intensive care
Medical personnel must have patience when treating unit and PICU survival. However, it is important to
lipoid aspiration. The majority of cases have an in- note that there are children with recurrent aspiration
dolent (inactive or slow) course as explained in the who have no apparent risks of dysfunctional swal-
pathophysiology section above. Therefore, the treat- lowing. These children are often misdiagnosed and
ment focuses on decreasing the acute and chronic in- can go months to years without being adequately
flammation and decreasing secondary injury from treated (121).
2831_Ch18_453-480 13/03/14 3:38 PM Page 473
be removed, can be misplaced and cause aspiration, reflux disease (GERD) rarely has any major compli-
and potentially increase the risk of upper airway in- cations in infants. GERD in infants can cause dis-
fections. Gastric tubes and gastrojejunal tubes are comfort, and the major treatment is to increase the
more permanent types of enteral feeding. These re- pH of the gastric contents to cause less pain. Com-
quire surgical procedures, increasing the risk of com- plications can arise when the gastric secretions are as-
plications, but they are relatively routine procedures pirated, which can cause significant lung injury and
in the surgical world (123). There is some evidence morbidity.
of fewer respiratory complications when placing the
distal end of the tube past the stomach (124). Pathophysiology
The pathophysiology of gastric and oral secretion
Glycopyrrolate
aspiration is closely linked. Reflux can occur and can
Glycopyrrolate is an anticholinergic medication cause damage to the esophagus and upper airway,
that inhibits the muscarinic receptors. These receptors but damage will not occur to the trachea and lower
allow salivation, and studies show that drooling and airway unless swallowing dysfunction is also present.
secretions are significantly decreased with its use. Prematurity and neurological disorders predispose
There are no data that suggest it improves respiratory children to both swallowing dysfunction and reflux.
status or decreases the likelihood of pneumonias (125). Muscle tone of the lower esophageal sphincter is fun-
damental to keeping gastric contents out of the
Tracheostomy esophagus and can be poor in both conditions. Re-
Tracheostomy is surgical procedure to place a tube flux and swallowing dysfunction can be seen in com-
through the trachea cutaneously to bypass the upper pletely normal infants, too, and can be silent as in
airway. It is used in children for a number of reasons, the aspiration of oral secretions (127).
one of which is persistent aspiration from oral secre- Gastric contents are acidic and full of enzymes that
tions. The tracheostomy tube allows the suctioning continue the breakdown of food for digestion. During
of these secretions in children who have a weak digestion, the pH of the stomach can reach 1 to 2 and
cough from neuromuscular disorders. Theoretically, when empty is 4 to 5. Acidity alone can cause an in-
this should decrease lung damage from continued as- flammatory response and cytokine release that will
piration, but no studies were found that have ex- damage the lung parenchyma. Repeated events will
plored this potential benefit. If a cuffed tracheostomy cause continued damage to the lung, as can recurrent
tube is used, it will further protect from aspiration. pneumonias from bacteria aspirated from the mouth.
Pepsin is the unique enzyme in the stomach that
Course and Prognosis breaks down dietary proteins. Pepsin can hydrolyze
Chronic aspiration rarely occurs in healthy children. lung parenchymal proteins and can be a major cause
However, it can cause persistent respiratory symp- of fibrosis in chronic aspiration of gastric contents.
toms, including wheezing, cough, chronic congestion, Pepsin has been used as a marker of chronic aspira-
and pneumonias (121). Chronic aspiration is an even tion, but the prevalence of respiratory symptoms de-
bigger problem in patients with other medical condi- veloping from gastric aspiration is still unknown (128).
tions. This is most commonly seen in former prema-
ture infants who have chronic lung disease. Their Clinical Manifestations
reserve is poor, and even the mildest of aspirations Clinical signs of gastric aspiration include the
can cause respiratory failure and more lung damage. following:
Persistent lung damage can cause pulmonary hyper-
tension and lead to heart failure. Children with neu- • Cough
rological and developmental abnormalities can have • Tachypnea
a number of these events before receiving medical or • Wheezing
surgical therapy, and their lung function could be lim- • Hypoxia/cyanosis
ited, at best, by then. Aggressive and early treatment • Recurrent pneumonias
of aspiration is extremely important in reducing the There are a number of studies used to diagnose
morbidities associated with chronic aspiration (126). reflux. It is important to note that the child must
have a swallowing dysfunction in order to aspirate.
Gastric Secretions A pH probe is the study of choice for reflux. There
are multiple ways the test can be done, but in general
The reflux of gastric contents is one of the most com- a probe is placed down the esophagus with multiple
mon symptoms seen in healthy infants and in infants ports that test for pH and/or fluid. The ports can tell
with numerous medical conditions. Gastroesophageal how high the reflux events are rising, as well as the
2831_Ch18_453-480 13/03/14 3:38 PM Page 475
about inhalation injury and possible systemic breath sounds on the right but poor breath sounds
complications? and wheezing on the left.
Jamie Lynn was doing well after intubation with • What are your concerns? What is the best
these vital signs: heart rate (HR), 104 bpm; blood way to further investigate your diagnosis?
pressure (BP), 104/72; RR, 24 breaths per minute; • What should we do next for Stephan?
pulse oximetry, 100% on 100% oxygen; and
■ Case 3: TJ Johnson
temperature, 99.4°F. The ABG values were
TJ Johnson is an 18-month-old boy who was
7.34/42/480, but the lactate was 4. The lactate
watching his dad in the family garage. The dad
test was repeated and came back at 5.4. The
was using an ethanol-based cleaner to remove
carboxyhemoglobin came back at 24%.
grease from one of his tools. He heard his son
• What is the potential concern? coughing and noticed TJ was holding the cleaner
• How do you treat it and what by-product in his hand. There were drips of the fluid on TJ’s
should be monitored? shirt, and the dad was concerned he may have
swallowed some of the cleaner and brought him
■ Case 2: Stephan Hyde
into the ED.
Stephan Hyde is a 2-year-old boy who comes into
the ED because his mother states he has been • What are the keys to deciding what TJ
wheezing for the last 2 days. The mother says he needs?
has no history of wheezing and has not been sick • What should you do next?
recently. When you listen to him, you hear normal • Should TJ be admitted or discharged?
Multiple-Choice Questions
1. What is the best ventilator change for a patient c. A 6-year-old boy who was found in a house
showing signs of worsening pulmonary edema? fire, has no respiratory symptoms, has vital
a. Decrease PEEP signs including a BP of 98/44, a RR of 34,
b. Increase PIP and carboxyhemoglobin of 48%
c. Increase PEEP d. A 2-year-old girl who was found in a house
d. Decrease FIO2 fire and was treated at an outside facility and
e. Increase respiratory rate transferred to you after 6 hours with normal
2. Which of the following is not a poor prognostic vital signs and mental status and a carboxyhe-
sign for a drowning patient in the ED? moglobin level obtained 5 hours ago of 48%.
a. CPR in the field 5. What is the first line of treatment for a pa-
b. CPR upon entering the ED tient who is thought to have carbon monox-
c. Initial pH of 7.3 on ABG laboratory test ide poisoning?
d. Fixed and dilated pupils a. Call to see if there is a hyperbaric chamber
3. Inhalation risk is at its highest in a patient available anywhere near your facility
who has b. Intubate the patient
a. High minute ventilation. c. Place the patient on 100% non-rebreather
b. Been exposed to a fire in an enclosed space. mask
c. Been exposed to a fire in which numerous d. Start sodium thiosulfate
chemicals and plastics were found burned 6. A child has a known hydrocarbon aspiration at
in the house. home. The child has no initial symptoms, but
d. All of the above the chest radiograph shows bilateral interstitial
4. Which patient below is best suited to undergo infiltrates. How should this patient be triaged?
treatment in a hyperbaric chamber? a. Admit
a. A 10-year-old boy who had a flash burn from b. Wait 6 hours and repeat the CXR
a gasoline tank explosion with facial burns c. Discharge
and a carboxyhemoglobin of less than 0.9% d. Check ABG values and if normal, discharge
b. A 17-year-old girl who was found in a fire of a 7. A 6-week-old infant born at 34 weeks has had
chemical plant, has altered mental status, a BP three recurrent pneumonias. A VFSS showed
of 70/45, and a carboxyhemoglobin of 58% aspiration of thin liquids past the vocal cords
2831_Ch18_453-480 13/03/14 3:38 PM Page 477
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infections due to direct and reflux aspiration in children sia. Pediatrics. 2008;121(2):253-259.
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41(5):329-334. use and the risk for community-acquired pneumonia.
120. Owayed AF, Campbell DM, Wang EEL. Underlying Ann Intern Med. 2008;149(6):391-398.
causes of recurrent pneumonia in children. Arc Pediatr 132. Srivastava R, Berry JG, Hall M, et al. Reflux related hos-
Adolesc Med. 2000;154(2):190-194. pital admissions after fundoplication in children with
121. Lefton-Greif M, Carroll JL, Loughlin G. Long-term neurological impairment: retrospective cohort study.
follow-up of oropharyngeal dysphagia in children BMJ. 2009;339:b4411.
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Chapter 19
Pediatric Neurological
Accidents Jennifer Schuette, MD
481
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Chapter Objectives
After reading this chapter, you will be able to:
1. Summarize the epidemiology of traumatic brain injury and spinal cord injury in the pediatric population.
2. Describe the pathophysiology of spinal cord injury and its potential effects on spontaneous respiration.
3. List the indications for endotracheal intubation in pediatric patients who have suffered a neurological injury.
4. Describe the best practices for intubating a pediatric patient with a neurological injury, including protecting
the cervical spine and minimizing the effect of the procedure on intracranial pressure in the patient with
known or suspected traumatic brain injury.
5. Describe the relationship between ventilator settings, intrathoracic pressure, and intracranial pressure.
6. Identify the risks of pulmonary complications in pediatric patients who have suffered a neurological in-
jury, as well as the possible thoracic comorbidities in the pediatric patient who has suffered multisystem
trauma.
7. Discuss various approaches to ventilator management in the pediatric patient who has suffered a traumatic
brain injury.
8. Define extubation readiness for a pediatric patient with a neurological injury.
■ ■ Upon Johnny’s arrival at the hospital, the trauma other components makes a compensatory change in
team begins a rapid assessment. His airway is intact, the opposite direction. For example, an intracranial
his lungs are clear to auscultation, and he exhibits hemorrhage that results from a TBI causes an in-
strong central and distal pulses. He does not open his crease in the volume of blood in the cranial vault. To
eyes to painful stimuli, is making incomprehensible prevent an increase in ICP, the health-care team
sounds, and withdraws from painful stimuli. Although must find a way to reduce the volume of intravascu-
the paramedic who assessed Johnny at the scene lar blood, brain tissue, or CSF. (This can be accom-
gave him a Glasgow Coma Score of 10, based on plished by evacuating [removing] the hematoma in
these findings his score is a 7, and the emergency the operating room, for example.) This basic princi-
room physician asks you to prepare for an endotra- ple guides many of the therapeutic interventions
cheal intubation. used in treating TBI (7).
Monitoring ICP requires placing a catheter in the
brain, an invasive procedure that can be done at
the bedside by the neurosurgical team (Fig. 19-4).
Intracranial Pressure During the initial management period of TBI in the
Intracranial pressure (ICP) is the pressure within the ED and early in the ICU course, it is not feasible to
cranial vault (the portion of the skull where the brain directly monitor ICP. Therefore, other mechanisms
is encased), and it is guided by the Monro-Kellie are used to estimate ICP and help guide therapy.
doctrine, which states that the total volume within ICP levels in healthy individuals fluctuate widely but
the cranial vault is strictly limited by the fixed walls are normally less than 10 mm Hg; in the setting of
of the skull. This volume is composed of the brain, illness or injury, most providers will intervene if
blood, and cerebrospinal fluid (CSF). If the volume ICP is greater than 20 mm Hg.
of one of these three components changes, ICP can In infants who still have an open fontanel (the
be maintained at a steady level only if one of the “soft spot” on the top of the skull, where the plates
2831_Ch19_481-502 13/03/14 3:36 PM Page 486
Intubation
Performing an endotracheal intubation to protect
the airway is widely practiced for patients who pres-
ent with a GCS score of 8 or lower (10). The treating
Figure 19-5 Types of Brain Herniation physician may also choose to gain control of the
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Box 19-1 Components of a Rapid Sequence by two-thirds and adding that to one-third of the
Intubation systolic pressure:
CPP = MAP – ICP
• Preoxygenation with FIO2 1.0
• Minimization of positive pressure mask The precise goals for CPP in pediatric TBI pa-
ventilation tients have yet to be established by a prospective
• Administration of rapidly acting medications randomized trial. A goal of 60 to 70 mm Hg is
• Cricoid pressure (Sellick’s maneuver) often used based on adult studies, but CPPs as
low as 50 may be sufficient in younger patients (23).
Adjunctive monitoring devices looking at cerebral
oxygen usage are sometimes used to more precisely
and aspiration), and the use of cricoid pres- assess the adequacy of oxygen delivery to the brain
sure. Medications should be selected that in any given patient.
provide adequate sedation, analgesia, and paralysis The tiered management strategies described in the
in a reliable and fast-acting fashion, with special at- following sections are suggested for all patients with
tention to avoiding any medications that might a severe TBI, defined as having a GCS score of 8 or
cause an increase in ICP. Specifically, ketamine less. This approach is based on expert consensus,
is a drug that has historically been avoided in with the top-tier therapies having a stronger base of
patients with TBI secondary to animal data that it is support within the scientific literature than those in
associated with an increase in ICP; more recently, the second tier (24). The physiological rationale for
the avoidance of ketamine use in this patient popu- each therapy is described with each intervention
lation has been called into question (18). Drugs that (summary in Table 19-2).
have a high risk for causing hypotension and a re- First-Tier Therapy
sultant decrease in brain perfusion (such as the
combination of a narcotic and a benzodiazepine) • Appropriate positioning: Head of the bed at
must be avoided. One approach is to anesthetize 30 degrees with the head positioned in the
with etomidate and then paralyze with rocuronium midline. This maximizes venous drainage from
for intubation. the head back into the systemic circulation.
• Adequate sedation and analgesia: Unad-
Limiting the Effects of Intubation on ICP dressed pain or agitation can increase
Intubation is a noxious stimulus that can result in the brain’s metabolic demand, which results
increased ICP, leading some providers to seek in- in increased blood flow to meet that demand.
terventions that would blunt this response. One • Normoventilation (PaCO2 of 35 to
approach has been to administer intravenous IV 40 mm Hg): Unless there is clinical
lidocaine prior to intubation in the hopes of anes- evidence of acute herniation (Cushing’s triad,
thetizing the airway. However, it is unclear if unilateral fixed and dilated pupils), the PaCO2
this practice has a significant protective effect should be maintained in the normal range. Hy-
(19, 20). The most crucial elements of airway man- poventilation must be avoided (Teamwork 19-1).
agement in patients with TBI are appropriate • CSF drainage: Pressure monitors can be placed
recognition of inadequate ventilation and/or oxy- in the space between the brain and the skull,
genation, avoidance of both prolonged hypercap- within the brain parenchyma itself, or within
nia and aspiration, and efficient insertion of an
artificial airway after achieving appropriate levels Table 19-2 Management of CPP
of sedation and muscle relaxation.
First Tier Second Tier
Cerebral Perfusion Pressure
Head of bed elevated Moderate hyperventilation
The approach to treating increased ICP in a patient 30 degrees Barbiturate coma
with TBI uses a tiered grouping of interventions (21). Head midline Moderate hypothermia
Although there may be some variations in this ap- Adequate sedation Decompressive craniectomy
proach among different providers, the approach and analgesia
described here is supported by the most recent Normoventilation
national guidelines published in the pediatric liter- CSF drainage with
ature (22). Interventions are often geared toward ventriculostomy
maintaining a goal cerebral perfusion pressure Neuromuscular
(CPP). CPP is equal to the difference between the blockade
ICP and the mean arterial pressure (MAP), approx- Hyperosmolar therapy
imated by multiplying the diastolic blood pressure
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after the injury has occurred (32). This, along Box 19-3 Common Causes for Inaccurate
with the low cerebral blood flow that generally ETCO2 Reading (63)
occurs regionally after a traumatic injury, could
result in ischemic injury to areas of the brain Inaccurate Numbers
that are potentially salvageable.
• Prolonged hyperventilation can result in a re- • High VD/VT ratios (dead space to tidal volume
bound effect on cerebral blood flow when nor- ratios)
moventilation is restored such that there is • Alterations in breathing patterns
actually supranormal flow in some areas as the • Large changes in VT
PaCO2 returns to normal; thus, any period of • Delivery of helium through ETCO2 device
hyperventilation must be followed by a wean- • High respiratory rate
ing phase to normalize the pH and PaCO2 (33). • High airway resistance (sidestream capnographs)
• High inspiration-to-expiration (I/E) ratios
Therefore, current recommendations for the man- (sidestream capnographs)
agement of patients with TBI are to use ventilator • Contamination of monitor or sampling system
strategies that maintain a normal PaCO2 except in with secretions or condensate
the case of impending or actual brain herniation. In • Leaks in ventilator circuit
that scenario, acute hyperventilation (PaCO2 of 30 • Leaks around ETT cuff (or presence of an
to 35 mm Hg) can be used until pharmacological uncuffed tube)
agents described in the first-tier therapies are avail- • Bronchopleural fistula
able, with PaCO2 being allowed to normalize as soon • Dialysis or extracorporeal membrane oxy-
as clinically feasible. Prophylactic hyperventilation genation (ECMO)
is not recommended because of the risk of ischemia False Negatives
described above (34, 35). Box 19-2 summarizes the
respiratory-based TBI management strategies. • Low cardiac output
With close management of PaCO2 necessary for • Severe airway obstruction
TBI, capnometry or end-tidal CO2 (ETCO2) monitor- • Pulmonary edema
ing is a preferred method for serial trending of CO2
levels. The American Association for Respiratory
Care’s clinical practice guidelines offer guidance on are delays in extubating patients with TBI even
the use and management of ETCO2 monitoring (36). after they meet normal extubation criteria (i.e.,
Care must be taken to correlate ETCO2 with PaCO2 adequate respiratory effort, intact protective airway
regularly to ensure accuracy of measurement, as well reflexes as demonstrated by a cough and gag, and
as to assess the reliability of ETCO2 readings. The the ability to maintain oxygenation and ventilation
common causes for inaccurate ETCO2 readings are with minimal positive-pressure support) (37). There
listed in Box 19-3. is no reason to think that the pediatric experience is
any different. Overall, there is a perception among
Extubation
pediatric intensivists that tracheostomies in pediatric
Little research has been done to determine the safety patients are underutilized for a variety of reasons
and appropriate timing of extubation and/or the use (38), and further work is required in this area to
of a surgical tracheostomy for children with severe maximize the rehabilitation potential of these high-
TBI. Research with adult patients suggests that there risk patients.
Box 19-2 RT Goals for TBI Management ■ ■ After Johnny is safely intubated, ongoing clinical
assessment reveals the following: afebrile, heart rate
1. Keep head of bed (HOB) at 30 or more degrees, of 52, and blood pressure of 164/98 while he is
even during mask ventilation. being bagged at a rate of 12. Pulse oximetry reveals
2. Incorporate ETCO2 as soon as it is available; a saturation of 98% on an FIO2 of 1.0. The surgical
this includes its use during mask ventilation. resident reexamines Johnny and notes that the right
3. Use acute mild hyperventilation (CO2 30 to pupil is large and does not respond to light, whereas
35 mm Hg) until other first-tier therapies are the left pupil is a normal size and responds briskly to
available light. The remainder of the physical examination is
4. Use continuous ETCO2 to drive ventilation. limited because of the sedation and muscle-relaxant
5. Use normoventilation (CO2 35 to 40 mm Hg) medications given for intubation. The trauma attend-
for duration of TBI care, with exceptions listed ing physician requests that you increase the rate at
above in item 3. which you are bagging to 20 to 25 times per minute.
2831_Ch19_481-502 13/03/14 3:36 PM Page 491
result in limitations in FVC. FVC has been There are a number of devices and therapeutic in-
shown to have predictive value regarding the terventions that can be used in the subacute phase
ability to maintain adequate gas exchange of recovery to assist the patient with respiratory
over a prolonged period of time without an muscle weakness (45). Some can be used prior to
unacceptable increase in WOB, as well as the patient being extubated, and others are measures
documenting early respiratory compromise to support the patient after extubation. It should be
in the setting of an acute illness during the noted that some have limited use in the pediatric
chronic management phase. population because they require a degree of cooper-
• Maximum inspiratory pressure (MIP) and ation that the youngest patients cannot provide.
maximum expiratory pressure (MEP): assess
the degree of inspiratory and expiratory mus- • Respiratory muscle training: daily exercises
cle weakness, respectively; the procedure for aimed at improving muscle strength
obtaining MIP and MEP is described in • Abdominal binders: prevent positional loss of
Chapter 17. lung volumes that can result from decreased
• Peak expiratory flow rate (PEFR): describes abdominal tone; adult studies have shown that
the maximum expiratory flow that can be an abdominal binder can increase spontaneous
generated during a forced expiration and is VT by as much as 16%, and it is therefore rec-
commonly used in the assessment of a patient ommended early in care (53).
suffering an acute asthma exacerbation (and • Noninvasive positive-pressure ventilation:
described in Chapter 13); a decline in this administered via face or nasal mask,
measurement may suggest progressive airway provides continuous positive airway pressure
obstruction as a result of plugging or infection. (CPAP) or inspiratory and expiratory airway
• Diaphragm fluoroscopy: This procedure pro- pressure (bi-level support, or BiPAP) to decrease
vides a radiological observation of diaphragm the likelihood of hypoventilation and atelecta-
movement during inspiration. As well as being sis in a patient with respiratory muscle weak-
useful in the acute phase of support to assess ness; these devices have a good track record in
the degree of function of the diaphragm in a other chronic respiratory diseases in childhood,
patient able to take spontaneous breaths, this such as cystic fibrosis and cerebral palsy.
study is also useful in the subacute period. Ap- • Diaphragm pacing: allows for electrical stimu-
proximately one-fifth of patients with loss of lation of a poorly functioning diaphragm
diaphragm function after SCI will have some through electrodes placed on the muscle or the
recovery of movement, and this study can be phrenic nerve that controls it (phrenic nerve
used to follow that progress over time as well pacing); this relatively new technology offers
as to assess the response of the diaphragm to the possibility of freedom from equipment
phrenic nerve pacing (52). and technology, at least for some portion of
• Video fluoroscopy/modified barium swallow: the day (52).
This study, which assesses a patient’s ability to • Airway clearance devices/techniques
complete a coordinated process of chewing and (discussed in detail in Chapter 14)
swallowing without evidence of aspiration, be- • Chest percussion and postural drainage
comes the longer-term assessment for a patient • Positive expiratory pressure (PEP) device:
with SCI. Because patients with SCI often have oscillating handheld apparatus that delivers
an impaired cough and gag reflex, it becomes vibrations to the airways during exhalation
important to identify the “silent aspirator” via a mouthpiece or mask, facilitating secre-
(described in Chapter 18) to prevent the long- tion clearance
term pulmonary damage that this can cause. • Insufflator-exsufflator device (described in
Additionally, patients who will require a more- Chapter 17): provides rapid cycling between
definitive feeding device, such as a gastrostomy positive inspiratory pressure and negative
tube, can be identified. expiratory pressure to simulate the effect of
• Sleep studies: These studies measure the EEG, coughing; should not be used for longer than
respiratory movement, and airflow throughout 5 minutes, and assistance may be needed to
the phases of sleep. These studies are particu- suction produced secretions.
larly useful in identifying those patients suffer- • High-frequency chest wall oscillation: vest
ing from the sleep-disordered breathing issues that oscillates the chest wall through rapid
described previously; a useful clinical sign of inflation and deflation of the device, which
such disruptions in normal sleep include failure increases airflow into the lungs and moves
to gain weight despite the delivery of adequate secretions into the larger airways for easier
calories. mobilization
2831_Ch19_481-502 13/03/14 3:36 PM Page 495
proposes that a sudden increase in ICP causes a dra- The chest radiograph will most commonly demon-
matic α-adrenergic catecholaminergic response. This strate bilateral pulmonary infiltrates, although NPE
then results in a rapid increase in the systemic and has been reported to occur unilaterally. Cardiac stud-
pulmonary vascular resistance—making it much ies (electrocardiogram, echocardiogram, and central
harder for blood to move through the vascular beds. venous pressure) will be normal unless there is
In the pulmonary circulation, this damages all three associated cardiac pathology such as a cardiac con-
of the anatomical components that separate the vas- tusion or decreased function secondary to hypoxic or
cular space from the alveoli: the pulmonary capillary ischemic damage suffered at the time of the initial
endothelium, the basement membrane of the alveo- injury.
lar capillaries, and the alveolar endothelium. Once The differential diagnosis should include aspira-
all three of these layers are compromised, there is tion pneumonia and, if the patient has been intu-
leakage of red blood cells and proteins into the alve- bated for more than 48 hours, ventilator-associated
olar space, resulting in the pink, frothy secretions pneumonia (VAP) (see Table 19-3). Aspiration pneu-
classically seen in pulmonary edema (56). monia is certainly a risk for patients with an im-
Also likely playing a role in the development of paired level of consciousness, especially if the airway
NPE is the systemic inflammatory response that was left unprotected for a prolonged period of time
develops in the setting of a significant neurological prior to hospitalization. NPE usually develops more
insult. A number of specific inflammatory media- quickly, whereas the signs and symptoms of aspira-
tors have been implicated, and many of these tion pneumonia and VAP tend to develop over a
substances have the direct effect of increasing per- longer period of time. In both types of pneumonia,
meability of the capillary endothelium. This leads one could also expect to see thickened, purulent se-
to the escape of red cells and plasma from the blood cretions as well as fever (although fever in patients
vessels (known as extravasation) into the pul- with brain injuries is common, making this sign
monary interstitium, and from there into the air somewhat less reliable).
spaces in severe cases. Interestingly, the cate-
cholamine release described previously can itself Management and Treatment
result in upregulation, or hyperresponsiveness, of The primary ventilator strategy to address
the inflammatory system (54). NPE is increased positive end expiratory pres-
sure (PEEP), which acts to decrease the transmural
Clinical Manifestations pressure gradient and minimize the amount of fluid
The clinical signs in NPE are similar to those seen in moving from the vascular space into the alveolar
patients with pulmonary edema caused by other space. One must keep in mind the theoretical effect
etiologies: hypoxia, tachypnea (if spontaneously that PEEP could have on the patient’s ICP; an in-
breathing), tachycardia, and pulmonary crackles crease in PEEP, if transmitted from the intrathoracic
noted especially at the bases are the most common space to the intracranial vault, could result in a
findings. Unlike pulmonary edema seen secondary higher ICP. Similarly, if the increase in PEEP leads
to left ventricular (LV) failure, an abnormal cardiac to a fall in the venous return from the intracranial
examination with extra heart sounds, like a gallop space, the cerebral blood volume could increase and
rhythm, is usually not present in patients with NPE. also result in increased ICP. Studies suggest, though,
Multiple-Choice Questions
1. What is the initial goal PaCO2 when ventilating 5. A sudden increase in pink-tinged secretions
a patient with a significant TBI? being suctioned from the ETT in a patient with
a. Less than 25 mm Hg TBI and cervical SCI is most likely caused by:
b. 25 to 30 mm Hg a. Pulmonary contusion.
c. 30 to 35 mm Hg b. Hemothorax.
d. 35 to 40 mm Hg c. NPE.
e. 40 to 50 mm Hg d. Tracheal injury.
2. Which of the following is unlikely to be the e. VAP.
cause of respiratory compromise in a patient 6. All of the following are appropriate therapies
who was intubated 24 hours ago for a GCS to reverse atelectasis in a ventilated patient
score of 6 after suffering a TBI when he was with TBI except:
struck by a car at a high rate of speed? a. Increase PEEP.
a. Atelectasis b. Increase PIP.
b. Pneumothorax c. Decrease rate.
c. Hemothorax d. Institute chest PT.
d. VAP e. Recruitment maneuvers such as inspiratory
e. Aspiration pneumonitis hold.
3. Which spinal nerves are responsible for ener- 7. Which of the following increases a TBI
vating the diaphragm? patient’s risk for an aspiration event?
a. C1 to C5 I. Delayed gastric emptying
b. C3 to C5 II. Loss of cough and/or gag
c. C5 to C8 III. Facial trauma
d. T1 to T3 a. I, II
e. T1 to T5 b. II, III
4. What should be the first intervention for an c. I, III
intubated TBI patient who has a sudden and d. I, II, III
marked elevation in ICP? e. None of the listed choices increase the risk of
a. Needle decompression of the thoracic aspiration.
cavity 8. Long-term respiratory support for a patient
b. Bolus dose of sedation with a cervical SCI at the level of C2 to C3 is
c. Bolus dose of paralytic medication most likely to include which of the following?
d. Manual ventilation to lower PaCO2 a. Tracheostomy and MV
e. Increase PIP on the ventilator b. Tracheostomy without MV
c. Intermittent BiPAP
d. Supplemental oxygen
e. Respiratory support is unlikely to be
required.
2831_Ch19_481-502 13/03/14 3:36 PM Page 500
9. All of the following are consistent with the 10. Patients presenting with TBI should have an
clinical presentation of a tension pneumotho- artificial airway placed if their GCS score is
rax in a multiple trauma patient whose injuries equal to or less than:
include a TBI except: a. 12.
a. Sudden drop in blood pressure. b. 11.
b. Sudden drop in oxygen saturation. c. 10.
c. Sudden drop in ICP. d. 9.
d. Decreased breath sounds on one side. e. 8.
e. Tracheal deviation.
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2. Tilford JM, Aitken ME, Anand KJ, et al. Hospitalizations
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19. Vaillancourt C, Kapur AK. Opposition to the use of
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3. Granacher RP Jr. Traumatic Brain Injury: Methods for
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9. Bullock R. Hyperventilation. J Neurosurg. 2002;96(1):
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10. Adelson PD, Bratton SL, Carney NA, et al. Guidelines for
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25. Hsiang JK, Chesnut PM, Crisp CB, Klauber MR, Blunt
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BA, Marshall LF. Early, routine paralysis for intracranial
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Section Six
Chapter 20
Ethics in Perinatal
and Pediatric
Respiratory Care Renee Boss, MD, MHS
Megan McCabe, MD, FAAP
503
2831_Ch20_503-524 13/03/14 3:35 PM Page 504
Chapter Objectives
After reading this chapter, you will be able to:
1. Identify four ethical principles that underpin modern bioethics.
2. Understand the obligations of professional competence.
3. Discuss the clinician’s duty when a medical error occurs.
4. Define professional ethics in the setting of a pandemic or public health emergency.
5. Describe how the best-interest standard is applied to medical decision-making in pediatrics.
6. Understand the differences between informed consent and assent for clinical care and research in pediatrics.
7. Understand the role of hospital ethics committees.
8. Describe moral distress in relation to caring for critically ill and dying children.
9. Explain the ethical issues and arguments around resuscitation of high-risk newborns.
10. Describe and apply the rule of double effect to symptom management at the end of life.
11. Discuss why non–heart-beating organ donation is currently controversial.
B
ioethics is the discipline dedicated to the ethi- professional ethics, including issues related to profes-
cal and moral complexities that arise during sional competence, medical errors, and duty to prac-
the course of biomedical research and clinical tice in a public health emergency. It also reviews topics
patient care. The field of bioethics draws from related to clinical ethics, including confidentiality, in-
knowledge and expertise in philosophy, law, history, formed consent and assent, goals of care, futility, and
theology, public health, and medicine. Bioethics in- conscientious objection. Finally, it examines how
tegrates these approaches in the formulation of guid- bioethical principles, professional ethics, and clinical
ing principles for the ethical practice of medical ethics interact in the care of pediatric patients with
research and patient care. This chapter reviews es- complex diseases (e.g., extreme prematurity, spinal
sential elements of both clinical and professional muscle atrophy type 1), as well as issues related to end-
ethics in medicine, providing an overview of how so- of-life care and organ donation.
cieties, health-care systems, individual clinicians, and
researchers share ethical responsibilities and duties Principles of Bioethics
in providing health care for patients and families.
Specific attention is given to the unique bioethical In practice, four ethical principles have guided much
concerns that may arise during the care of children of patient care and research since the 1970s: auton-
and their families (1). omy, justice, beneficence, and nonmaleficence (3).
2831_Ch20_503-524 13/03/14 3:35 PM Page 505
Table 20-1 Five Philosophical Frameworks for risks, benefits, and predicted outcomes—so that pa-
Moral Decision-Making tients can make educated decisions. It also confers a
duty for clinicians to elicit, respect, and incorporate
Philosophical patients’ goals, values, and wishes into their treat-
Framework Approach to Moral Issues
ment plans.
Utilitarian The decision should generate the Autonomy is generally a right given to adults who
greatest good for the greatest have the capacity to make independent decisions
number of people. about their medical care. When the patient is a child,
Justice The decision must treat everyone however, the principle of autonomy typically refers
fairly. to the rights of parents to make decisions for their
child. Parents’ rights to make decisions for their
Rights The decision must respect moral
child’s medical care must be respected as long as they
rights (e.g., to privacy, to not be
do not endanger, abuse, or neglect the child (4). For
injured).
children who are in the custody of the state as a re-
Virtue The decision should promote the in- sult of abuse or neglect, state-appointed social work-
dividual reaching his or her highest ers and lawyers will act as decision-makers regarding
potential (e.g., for honesty, compas- medical care. When patients are very young, they are
sion, courage). not generally allowed any substantive voice about
The Common The decision must enhance the their medical care. A 1-year-old child, for instance,
Good common good of a group/ is not permitted to refuse a vaccination that the par-
community/society. ent requests. Distraction, deception, manipulation,
and limited physical or chemical restraints may be
permissible in some settings in which a young child’s
noncompliance interferes with a medical treatment
These principles should guide all patient care inter- felt to be in the child’s best interest (Box 20-1).
ventions (Fig.20-1). Children’s right to and capacity for autonomy
increases with their emotional and cognitive develop-
Autonomy ment. Adolescents can often contribute in an edu-
The term autonomy represents a person’s right to cated and thoughtful way to decisions about their
make decisions that are based on his or her personal own medical care or participation in research. Pread-
values, without undue influence from others, includ- olescents may be able to understand enough about a
ing family members or clinicians. This means, for in- particular medical decision that it is appropriate to
stance, that patients have a right to decide to forgo engage them in expressing their wishes about care. As
chemotherapy for advanced cancer if they believe discussed later in this chapter, respecting autonomy
that the length of their life is less valuable than the for older children often entails ensuring informed
ability to live their days without the burden of med- consent from parents and informed assent from the
ications and hospitalization. Patients’ right to auton- pediatric patient (Special Populations 20-1).
omy confers a duty on clinicians to provide enough
information about diagnosis and treatment—the
Box 20-1 Enhancing Compliance With
Pediatric Patients
● Special Populations 20-1 not different from those that govern research in
adults: respect for persons, justice, and beneficence.
Emancipated Minors and Medical Applying these principles to research in children is
Decision-Making made even more complex by children’s developmen-
tal variability and ability to give assent, additional
Emancipated minors are children younger than 18
concerns about risk in a vulnerable population, and
who live independently of their parents. Emancipated
the intricacies of family decision-making. It is the
minors may consent to or refuse medical care as if
role of an institutional review board to evaluate the
they were adults. The criteria and process for eman-
risks and benefits involved in research protocols
cipation vary by state and courts, but generally in-
(Special Populations 20-2).
clude the following:
• Live separately from their parents Beneficence and Nonmaleficence
• Are financially independent or self-supporting The principle of beneficence obligates clinicians to
• Have parents who surrendered their rights and provide care that will be beneficial to the well-being
responsibilities of the patient and will serve the best interests of the
• Are married patient. Care provided in this context may include
• Have entered into active military service cure of disease, relief from pain, or enhancing health
and quality of life. Social and spiritual support of
patients and families are important.
The principle of nonmaleficence obligates clinicians
Justice to care for patients in a way that causes no harm. Pro-
The principle of justice requires health care to be de- tecting a patient from harm may include adequate
livered fairly, so that no one patient group unduly pain and symptom management, avoiding burden-
suffers the burden of scarce resources. Justice means some therapies that have minimal chance of improv-
that all individuals have a right to equal access to ing the patient’s well-being, and treating the patient
medical care and to a minimum standard of health with compassion and honesty. Medical treatments
care. It means, for instance, that children living in frequently entail some level of harm or risk to the
the poorest areas of a city should have the same ac- patient; the principles of beneficence and nonmalefi-
cess to a minimum standard of skilled medical care cence often have to be weighed against each other
as those living in the richest areas of a city. The ideal when determining what is in the patient’s best interest.
of equal access to medical care is obviously con-
strained by the resources that are readily available Professional Ethics
in a particular setting. Governments, health-care
systems, and individual clinicians often have to set Professional ethics address the interactions among
priorities about the medical care that can be deliv- professionals, individuals, and society. Professional
ered within those constraints. Justice does confer a governing bodies develop standards of behavior
level of responsibility for health-care providers to for their members. The American Association for
improve the health status of community members
who might be fundamentally harmed by poverty,
racism, or inequality. Justice also confers upon cli-
nicians and health-care systems a duty to demon- ● Special Populations 20-2
strate cultural competence so that medical care
can be delivered effectively and compassionately to Research in Infants and Children (53)
diverse populations. Subpart D of The Common Rule is often used by insti-
In clinical research, respecting the principle of jus- tutional review boards to determine the acceptability
tice requires that all people have an equal opportu- of risk posed by research participation in the pediatric
nity to become participants in human subjects population. Subpart D stipulates the following:
research. Particular protections for vulnerable pop- • Healthy children may only participate in research
ulations, such as pregnant women and children, have that involves no more than minimal risk.
evolved because there has been greater realization of • Children with a particular illness or disease may be
the injustice of denying novel medical therapies to eligible to participate in research of greater than
these populations (6). In the past 15 years, there has minimal risk if the research offers them a potential
been a move away from the historical prohibition direct benefit.
against research in children. Since 1998, the National • Children without a particular disease may partici-
Institutes of Health have required that children be pate in research involving a minor increase over
included in human subjects research protocols, ab- minimal risk if the research will provide vital infor-
sent a compelling reason to exclude them (7). The mation about a particular disorder.
ethical principles that govern research in children are
2831_Ch20_503-524 13/03/14 3:35 PM Page 507
inspiratory positive airway pressure (IPAP) of 20, as 98,000 people die from medical errors yearly in
expiratory positive airway pressure (EPAP) of 6, and the United States (12). Since that report’s publica-
fractional concentration of inspired oxygen (FIO2) tion, many health-care systems have put large-scale
of 21%. While you look over the settings on the quality and safety initiatives into place to help iden-
machine, you see that it has been set for a backup tify and prevent medical errors. In addition to this
rate of 20 and an IPAP of 12. The EPAP is 6, and effort, most institutions have developed guidelines
the FIO2 is 21%. for disclosing errors to patients and their families.
To many people in health care, this has been a sig-
nificant cultural change. In the past, although er-
rors did occur, they were rarely addressed openly
A medical error implies a preventable adverse with patients and families. However, on multiple
event—a threat to patient safety that could have been levels, there are ethical reasons to disclose errors to
avoided. A medical error may cause a patient to ex- patients.
perience an avoidable infection, injury, medication Patient safety can be compromised both as the re-
overdose or underdose, misdiagnosis, or even death. sult of an inherent risk of medical treatment or as
Medical errors may or may not result in actual pa- the result of an error. Inherent risks include those
tient harm; errors that do not cause patient harm are unavoidable harms that are known to occur in a de-
often called “near misses.” fined population as a consequence of a medical treat-
The Institute of Medicine’s 2000 report To Err is ment. For instance, a certain number of patients will
Human estimated that at least 44,000 and as many suffer from laryngeal edema following extubation,
and some of those patients may require reintubation
to protect their airway. In this case, patient safety is
not compromised due to a mistake on the part of the
Teamwork 20-1 Unsafe Staffing health-care provider but as a known adverse effect
Levels of translaryngeal intubation. Another example of in-
herent risks associated with medical care includes
MOST HOSPITAL DEPARTMENTS HAVE A MINIMUM medication side effects, such as tachycardia following
STAFFING LEVEL, OR THE NUMBER OF RTS NEC- a nebulized bronchodilator. Clinicians have an obli-
ESSARY TO PROVIDE SAFE PATIENT CARE DURING gation to anticipate and disclose these foreseeable
AVERAGE ACUITY. Patient care acuity, however, can events and the likelihood of their occurrence to
increase rapidly, and staff members have to feel patients before providing the medical treatment or
confident enough to speak up to front-line supervi- intervention. When the inherent risk is potentially se-
sors if they are unable to complete their assigned vere, such disclosure may take the form of a formal-
patient care for any reason. There are several tech- ized written informed consent.
niques you can use as a front-line RT to ensure that Medical errors can occur in any health-care set-
you or one of your coworkers are not sacrificing ting, although they are most common in settings
the care of one patient while working with another: where highly technical care is delivered, such as in-
• Check in at regular intervals with coworkers. tensive care units. In 2007, the Joint Commission
This is particularly important for RTs, who found that as many as half of all serious adverse
frequently work in multiple units or may not medical events were due to poor communication—
always see or hear what other RTs are doing. between clinicians and patients and between clini-
• Know how to contact your coworkers when cians and other clinicians (13).
you need help. Do they have a pager number? Although individual clinicians may make errors
Is there a lead or floating therapist assigned during the care of patients, it is the duty of a med-
to help others? ical system to have in place multiple routine checks
• At the beginning of the shift, identify a thera- and balances to prevent, detect, and ameliorate mis-
pist with a lighter assignment or one who may takes made by individuals. Some of the interven-
be able to help when other assignments increase. tions aimed at decreasing medical errors include
• At the beginning of the shift, identify the RT computerized documentation and order-entry sys-
who is most likely to experience a rapid increase tems that eliminate problems from poor handwrit-
in acuity in his or her patients. This could be ing, automated allergy notifications, work hour
someone with the largest number of patients or limits, standardized methods for handoffs of patient
the one with the highest number of open beds information, and certified hospital translators. In-
in the unit. It could also be the therapist in a creasingly, efforts are being made to educate patients
surgical unit who will be receiving many post- about the steps they can take to minimize the chance
operative patients throughout the shift. of a medical error, such as asking clinicians to wash
their hands, asking surgeons to initial the targeted
2831_Ch20_503-524 13/03/14 3:35 PM Page 509
involved in these situations may experience moral instance, if an extremely premature infant has no more
distress or compassion fatigue. than a 5% chance of surviving the neonatal period,
some would argue that it is unclear whether aggres-
Confidentiality sive intensive care is in that infant’s best interest (20).
Several professions have an obligation to respect In such a scenario, the clinicians may believe that it
confidentiality, including health-care providers and is in the infant’s best interest to provide only palliative
lawyers. Medical confidentiality refers to clinicians’ care, while the parents may believe it is in the infant’s
duty to not reveal information disclosed to them by best interest to pursue all intensive therapies that have
a patient or about a patient. This duty reflects the any chance of prolonging life. When faced with con-
ethic of respect for persons. Legal protection for flicts like this, clinicians should strive to reach under-
medical confidentiality is not absolute; clinicians do standing and compromise through the process of
have an obligation to breech patients’ confidentiality consistent, compassionate, and truthful communica-
if they disclose that they have, or they plan to, harm tion. In addition, careful consideration should be
themselves or others. This means, for instance, that given to the ways in which a family’s culture, religion,
a clinician must make a legal report if a mother re- and beliefs shape their values and decisions. It is
veals that she is physically abusing her toddler. important to involve individuals whom the family
In pediatrics, conflicts regarding confidentiality identifies as important counselors to them, such as
can arise when parents ask clinicians to refrain from extended family members or community religious
telling children about their medical condition, treat- leaders. For those cases in which clinicians feel that
ments, or prognosis. For example, a father may re- families are not making reasonable decisions for their
quest that a child not be told that she has cancer. child, it may be necessary to involve the hospital
Conflicts about confidentiality can also arise when ethics committee and/or legal counsel. In extreme
children ask clinicians not to reveal information to cases, the legal system may take over responsibility
their parents, such as the results of a pregnancy for guardianship and decision-making.
test. In each case, the clinician’s role is to under-
stand why the patient or parent wishes to withhold Informed Consent
the truth. Through discussion of the risks and ben-
efits both of disclosing and of withholding the in- ■ ■ Six months after Daniel’s surgery, he is back in
formation, the clinician can often assist in creating the hospital. You are working on the pediatric in-
a safe and respectful space where the information patient floor again and go into Daniel’s room to help
can be shared. with his chest physiotherapy regimen. He continues
The rise in the use of social media by health-care to weaken from his muscular dystrophy. He tells
providers has posed new concerns about patient you he is back in the hospital to be part of “an
confidentiality. Using the internet to share informa- experiment.” You ask him what kind of experiment,
tion about patients, whether in the form of photo- and he tells you “I don’t really know, but my parents
graphs or text, violates confidentiality. Increasingly, signed me up, and they hope it will help me get
hospital medical training programs are developing better.”
strict staff policies about the use of cameras and
social media (19).
The concept of informed consent is based on a
Best-Interest Standard duty to honor patient autonomy. It requires clini-
Because children possess, at best, a limited degree of cians and researchers to provide the facts and infor-
autonomy, they are never considered legally compe- mation that a patient needs to make a reasoned
tent to make medical decisions. Morally and legally, decision; it requires patients to have the ability to ex-
it is the parents’ right to make decisions for their ercise reasoned judgment (21). Obtaining informed
child. The goal of these decisions is that they are in consent from a patient or research participant in-
the child’s best interest. The best-interest standard volves much more than acquiring a signature; true
holds that decisions should ideally maximize the informed consent is a process that requires clear
child’s welfare. In fact, parents are only held to a communication about risks and benefits, adequate
standard of making a decision for their child that is time for questioning and understanding, protection
reasonable. That is to say, families do not have to from undue influences, and transparency about the
make the best decision for their child as judged by right to revoke consent at any point. Informed con-
doctors or by the court as long as their decision does sent requires veracity, or truthfulness, on the part of
not diverge too far from what clinicians and societies the clinician.
define to be reasonable. Informed consent can only be provided by a legal
Determining what is in a child’s best interest adult 18 years or older. In pediatric medicine and pe-
can sometimes be ambiguous and conflicted. For diatric clinical research, usually one or both parents
2831_Ch20_503-524 13/03/14 3:35 PM Page 511
not obligated to provide futile care, and in fact they RTs may feel moral distress about performing
have an ethical obligation not to provide futile care terminal extubations during withdrawal of me-
that will cause undue suffering for the patient. Futile chanical ventilation (MV), particularly if they feel
care violates the principle of nonmaleficence. inadequately prepared to participate in end-of-life
Determining which interventions are unequivo- care (28, 29). The differing roles and experiences of
cally futile is fraught with some ambivalence. There multidisciplinary team members can result in con-
is no national or international agreement about how flict; families often perceive this conflict and find that
small the chance of therapeutic benefit must be for a it undermines their trust in medical care. Clinicians
treatment to be considered futile or medically ineffec- can best manage these conflicts when the environ-
tive. Interventions that clearly fall out of the standard ment makes it safe for them to communicate hon-
of care for similar patients with similar diseases are estly with each other (30).
most clearly defined as futile. For instance, extracor- When clinicians do not have an opportunity to di-
poreal membrane oxygenation (ECMO) is considered rectly address their moral distress and receive support
medically futile in infants who have pulmonary hy- from colleagues, compassion fatigue and burnout can
poplasia caused by lethal osteogenesis imperfecta; not occur. Compassion fatigue results from ongoing stress
only does this treatment not cure the pulmonary hy- in health-care providers who do not have adequate
poplasia, but it also poses a risk of significant addi- ability or time to engage in self-care practices. Symp-
tional harm to the patient. On the other hand, many toms of compassion fatigue can include apathy,
interventions are believed to have a small or uncertain anger, anxiety, self-doubt, difficulty focusing, work
chance of benefit to the patient. There may be dis- absences, and substance abuse. Unaddressed compas-
agreement among professional medical societies, in- sion fatigue may lead to burnout and cause clinicians
dividual clinicians, and families about which of these to experience difficulties in their job or to consider
interventions might be futile (24). In these cases, cli- leaving the health-care field (31, 32).
nicians should look for guidance from their institu- When clinicians’ moral objection to the care for
tion’s policies, the hospital ethics committee, and state a particular patient or group of patients is strong,
law regarding medically ineffective care. they are permitted to withdraw their participation in
that care. The terms conscientious objection and con-
Moral Distress scientious refusal refer to clinicians’ moral and legal
Moral distress describes the dilemma clinicians ex- right to not provide care that they find ethically ob-
perience when they are prevented from doing what jectionable (33). The legitimacy of clinicians’ personal
they feel is best for their patients or when they feel moral beliefs is permitted to exceed their professional
obligated to do something they believe is not in their responsibilities in this setting, with the goal of protect-
patients’ best interest. A clinician, for instance, ing their integrity and self-respect. Medical institu-
might experience moral distress when asked to per- tions generally have a written policy for conscientious
form cardiopulmonary resuscitation (CPR) for a refusal, which describes the steps clinicians must take
5-year-old who is dying from end-stage cancer. Cli- in order to decline care of a patient. Conscientious
nicians treating children with HIV in Africa might refusal, while protecting the rights of clinicians, does
feel moral distress when they cannot obtain the an- have the potential to infringe on patients’ rights.
tiretroviral treatments for their patients that they If, for example, a neonatologist refuses to intubate a
know are available in other countries. Clinicians may newborn with Trisomy 18 as a matter of conscien-
feel moral distress about perceived unsafe staffing tious objection, this may obstruct the infant’s right
levels in their intensive care unit (25). Moral distress to medical care (34). When terminating their partici-
commonly occurs when families request, or deny, pation in a patient’s care because of conscientious
therapies that clinicians feel strongly about. Given refusal, clinicians have a duty to transfer that care
the ethical and legal deference given to the right of to a qualified health-care provider and to continue
parents to make decisions for their children, clini- providing that care if the patient’s health is at signifi-
cians may often feel they do not have a right to deny cant risk.
that autonomy (26).
Because of the different roles and responsibilities
that multidisciplinary members of a health-care
team have when caring for patients, members of that ■ ■ You don’t see Daniel again until 3 years later,
team often experience moral distress in ways that re- when he has been admitted to the PICU. This time,
flect their roles. Physicians, for example, often feel the he has been admitted after developing ventricular
greatest moral responsibility for denying requests for tachycardia related to cardiomyopathy. He is intu-
medically ineffective care; nurses may experience bated and needs to have a defibrillator placed. One
the greatest moral distress around issues of quality of the residents on the case is wondering if this con-
of care or breakdowns in team collaboration (27). stitutes futile care because Daniel is likely to die from
2831_Ch20_503-524 13/03/14 3:35 PM Page 513
muscular dystrophy. An ethics consult is requested. other settings, representatives knowledgeable about
After discussion with Daniel (although he is intu- pediatric medicine participate in the larger hospital
bated, he is able to use his computer for communi- ethics committee that reviews both adult and pedi-
cation), his family, and the treating medical team, the atric cases. Hospital ethics committees should be
hospital ethics committee supports the decision to consulted whenever there is uncertainty or disagree-
pursue a defibrillator. The defibrillator is placed, and ment about the ethical permissibility of a particular
Daniel is able to be extubated after a long period of area of clinical care. For instance, hospital ethics
intubation. During this hospitalization, there are sev- committees are commonly consulted to comment on
eral meetings with his family and both out-patient conflicts between clinicians and families about what
and in-patient medical teams. They agree that, when is in the patient’s best interest. Many hospitals also
Daniel is better able to speak for himself, they will require that an ethics consultation occur routinely as
discuss with him the possibility of tracheotomy part of certain clinical protocols, such as during a
and long-term MV and develop a plan for decision- determination of medically ineffective treatment.
making. Daniel goes home and returns to school. An ethics consultation may be requested by any
member of the medical team, any hospital staff mem-
ber, or any family member. The hospital ethics com-
mittee may provide consultation either by individual
The Joint Commission mandates that all hospitals committee members, by subgroups of the committee,
formalize a procedure for addressing ethical conflicts or by the committee as a whole. Committees generally
that arise during the care of patients. Most hospitals invite involved multidisciplinary clinicians, family
satisfy this requirement by maintaining one or more members, and if appropriate, the patient to partici-
hospital ethics committees, comprising multidiscipli- pate in the consultation and present their perspectives
nary members from both the medical and lay com- about the issue at hand. The ethics committee then
munities. The chair of the hospital ethics committee proceeds with careful deliberation of the clinical sce-
generally has some level of advanced training in nario in light of normative ethical principles. The
bioethics. Although committee members are not re- documented findings of the hospital ethics committee
quired to have extensive ethics training, they should are generally included in the patient’s medical record.
have enhanced skills and interests that increase In addition to providing consultation for indi-
their expertise beyond that of the average clinician vidual clinical cases, many hospital ethics commit-
(Fig. 20-2). The role of hospital ethics committee tees play integral roles in the development of
members is to act as advisors, arbitrators, and ethical hospital protocols to address ethically complex
experts to the health-care team. Hospital ethics clinical scenarios, such as organ donation, estab-
committees do not have the authority to make med- lishing goals of care, and do-not-resuscitate orders.
ical decisions; this authority remains with the pa- Hospital ethics committees also often participate
tient’s medical team. Hospital ethics committees also in organizational policies and business ethics for
are not acting in the capacity of legal counsel, even which they may contribute to administrative guide-
though questions posed to the committee sometimes lines, such as receiving gifts from pharmaceutical
overlap with concerns about legal permissibility. companies. Most hospital ethics committees en-
In some hospitals, separate ethics committees are gage in education of the wider medical community
established to specifically address pediatric issues; in about ethical issues related to patient care.
Health Policy Ethics
Clinical ethics also inform health policy on a na-
tional and international level. Health policy ethics
focus on broad issues that have an impact on the
way health care is delivered across a variety of set-
tings. Questions about human rights, access to es-
sential medicines, stem cell research, responsible
biotechnology, and national health care are just
some of the concerns of health policy ethics. In the
United States, the Presidential Commission for the
Study of Bioethical Issues works with the president
to establish policies that promote ethically respon-
sible clinical medicine and medical research. Histor-
ically, the commission has published statements
concerning such topics as caring for the aged,
Figure 20-2 Hospital Ethics Committee (© Thinkstock) human cloning, and biotechnology.
2831_Ch20_503-524 13/03/14 3:35 PM Page 514
Clinical Scenarios With Ethical legal implications. The legal implications require an
understanding of both federal and state law, and
Implications for Pediatric hospital policies drafted with the participation of
Respiratory Care hospital counsel will reflect both federal and local
regulations. Professional societies such as the AAP
There are many scenarios in a pediatric RT’s daily
have published guidelines for decision-making re-
responsibilities that have the potential to cause ethi-
garding high-risk newborns (35). These guidelines
cal dilemmas. This section describes several of the
do not provide specific algorithms but rather create
more common scenarios, the ethical implications,
a framework for practitioners (Fig. 20-3). The eth-
and some strategies to employ to address them.
ical framework used by these guidelines is interest
Newborn Resuscitation in Cases of based, meaning that decisions should be made
based on what is perceived to be in the patient’s best
Extreme Prematurity or Severe interests. Ethicists use this approach in part because
Congenital Anomalies principle-based approaches (e.g., beneficence, auton-
Newborn resuscitation is an extremely common pro- omy) are often difficult to integrate with real-world
cedure. The goal is to support infants during the decision-making because often the principles will
transition from fetal life to independent respiration conflict. In cases of adults who cannot make deci-
and circulation. For most newborns, this is the sim- sions for themselves, an interest-based approach
ple act of drying and stimulating the infant, assess- (i.e., “What is in the best interest of the patient?”) is
ing for good perfusion and respiratory effort, and well accepted. Using this approach for infants rests
subsequently passing them over to proud and ex- on the fundamental assumption that infants are in-
cited parents. For the preterm infant or the infant dividuals with rights and interests equal to all other
with congenital anomalies, neonatal resuscitation individuals, regardless of chronological age. Because
can go far beyond these routine maneuvers. Intuba- infants are developmentally incapable of expressing
tion, vascular access, CPR, or other invasive proce- and advocating for their interests, clinicians rely on
dures may be required within the first minutes after surrogate decision-makers to answer the question
birth. These children need the support of a newborn “What is in the best interest of the patient?”
intensive care unit for days to months as their bodies Determining the best interest of an individual pa-
adjust to extrauterine life. As advances in both res- tient requires an examination of rights. In the case
piratory technology and medical care have allowed of high-risk newborns, there are several individuals
the immediate survival of many infants who would and groups to consider. First is the newborn, fol-
otherwise not survive, the ethical dilemmas faced by lowed by the family (parents and siblings), and
care providers have become stark and frequent. This finally the medical team and larger society. The rights
is true both for infants at the threshold of viability of the infant are primary in this discussion, although
and those with severe congenital anomalies. Al- not solely important. The infant first has the right to
though technology can save lives, it can also serve life and therefore medical treatment that sustains life.
to sustain bodily function at times when recovery or This right is fundamental but not inviolable, meaning
future development is impossible, thereby prolong- that in certain situations other rights may take prece-
ing suffering and delaying but not preventing death. dence (36). The infant also has a right to justice, or
This section reviews the ethical challenges created equal treatment, unless there is a moral reason for
by the question of when and how to best support
these ill and fragile infants and their families.
Ethical questions may arise even before an infant
is born. Prenatal screening with ultrasound and
maternal blood work has allowed the earlier identi-
fication of some severe congenital anomalies. This
provides families and health-care providers the op-
portunity to make decisions regarding maintenance
versus termination of a pregnancy. If the pregnancy
is maintained, a plan for the delivery and the support
provided to the infant after birth becomes the central
question. This same decision-making process may
need to occur in an abbreviated time frame when a
woman develops preterm labor at 23 weeks’ gesta-
tional age.
The decision regarding which infants to resusci- Figure 20-3 Neonatal Resuscitation Team (Courtesy of
tate and how to resuscitate has both ethical and Keith Weller)
2831_Ch20_503-524 13/03/14 3:35 PM Page 515
End-of-Life Care lead to apnea, and therefore they fear that by treating
the patient’s dyspnea, they will in fact hasten or cause
■ ■ Eighteen months after his last hospital stay, the patient’s death. Medical providers and ethicists
Daniel returns to the hospital with respiratory failure agree, however, that the provision of narcotics to a
that is a result of his muscular dystrophy. This time dyspneic patient is ethically permissible under what
he cannot be weaned from the ventilator. His parents is known as the rule of double effect.
and primary care team report that, during his time at The rule of double effect states that an action that
home, Daniel repeatedly informed them that he did is known to have two possible effects, where the in-
not wish to live with a tracheotomy or chronic venti- tended one is beneficial and the unintended one
lation. The clinical psychologist who has worked with is not beneficial, can be morally permissible under
Daniel spends a long time reviewing the issue with specific circumstances. These circumstances are as
him. He continues to refuse a tracheotomy, and all follows:
who interact with him believe that this is a reasoned • The act itself must be either good or morally
decision. He and his parents determine a time for neutral.
him to be extubated after other family members and • The person must be acting with good intent.
friends can be present for a life celebration. They re- • The bad effect is necessary to achieve the good
quest that all comfort measures be provided but that effect.
he not undergo CPR, reintubation, or noninvasive • The good effect must be more significant than
ventilation. The cardiology team turns off his defibril- the bad effect (3).
lator prior to extubation.
How does this affect the patient with dyspnea at
the end of life? The intended effect of the morphine
is relief from air hunger. The unintended effect is the
RTs often participate in end-of-life care potential of narcotic medications, including mor-
when newborn or pediatric patients die. As phine, to decrease a patient’s drive to breathe, which
discussed in the section on resuscitation of high-risk can result in an ineffective respiratory rate or even
newborns, patients may die when life-sustaining in- apnea. If we examine the provision of morphine to
terventions are not performed, when they are not a dyspneic patient, what do we find?
successful, or when they are withheld. The most com- • Is it a good or morally neutral act?
mon end-of-life scenario involving RTs is terminal Providing the patient with relief is a good act.
extubation. Terminal extubation is the removal of MV To meet this criterion, the medication given must
and the endotracheal tube (ETT) from a patient who be known to provide relief of the symptom
is expected to die. being treated. Other sedative medications, which
Although the management of patients during the can also decrease respiration, are not known to
process of withdrawing life-sustaining therapies is a provide relief of dyspnea, and therefore adminis-
medical procedure, there are some ethical issues that tering them for this purpose would not be a
are important for all participants to understand. good act.
Withdrawal of life-sustaining therapy does not mean • Is the provider acting with good intent?
that the patient is no longer receiving care. Care at By using morphine, the medical provider is at-
the end of life is medical, psychosocial, and spiritual. tempting to relieve a distressing symptom and
Aggressive symptom management is a key part of therefore is acting with good intent. If the inten-
end-of-life care. The goal of symptom management tion is to cause apnea leading to death, this
is to provide comfort; it does not seek to extend life would not be an action with good intent. It is
or hasten death. important to distinguish the difference between
In patients who have respiratory failure, one very actions that may allow death to come faster
common symptom is dyspnea, also called air hunger. (hastening death) and actions that directly lead
It is a subjective experience that patients describe to death (killing).
as uncomfortable. It can be unusual awareness of • Is the bad effect necessary to achieve the good
breathing or breathlessness. Narcotic medica- effect?
tions such as morphine can be effective in Finding the appropriate balance in dosing does
treating the sensation of dyspnea, although they pro- require careful titration of the medication, but
vide no improvement in lung function. The fact that the bad effect of morphine (respiratory depres-
narcotics relieve dyspnea in patients is well known, sion) is not required to relieve dyspnea.
but many medical providers express reluctance or • Is the good effect more significant than the bad?
anxiety about prescribing them at the end of life. Given that the patient is receiving palliative care
They hesitate because they also know that narcotics and the primary goal is relief of suffering and
can suppress a patient’s respiratory drive and even provision of comfort, improving the distress
2831_Ch20_503-524 13/03/14 3:35 PM Page 519
The typical process for DCD is as follows: A pa- when death occurs and when irreversibility sets in.
tient or the patient’s family has requested planned Although the dead donor rule outlines criteria for
withdrawal of life-sustaining therapy and has also death, it does not give a time frame. Some ethicists
requested that resuscitative measures (e.g., CPR, in- argue that this uncertainty is unacceptable, and
tubation) not be initiated. They have also requested therefore removal of organs within a time frame in
that the patient be a candidate for organ donation. which the patient may not be truly dead (defined
After the donation-consent process is complete, the by them as irreversibly despite intervention) is un-
patient undergoes the planned withdrawal of life- ethical. In fact, some go so far as to say that the
sustaining therapies. If he progresses to death within organ-procurement process is the act that kills the
1 hour after withdrawal, he is observed for a number patient (49).
of minutes (which varies by institutional policy) for Other ethicists take a different approach, claiming
return of spontaneous circulation or respiratory that there is a distinction between irreversible death
effort. If he is simultaneously unresponsive, apneic, and permanent death. Those who take this stance
and pulseless for the duration of the observation pe- argue for the recognition of several stages of death
riod, he is declared dead, and organ procurement will after the initial end of vital functions. The first stage
begin. If he does not die within the hour waiting pe- is a period in which autoresuscitation, or the return
riod, he is no longer a donation candidate and con- of breathing and pulse may occur. The second stage
tinues receiving comfort measures during the dying is one in which death is permanent without interven-
process. tion but could be reversible if intervention occurs.
There are several reasons why this process is con- The third stage is one in which death is permanent
troversial. The first has to do with what is commonly and irreversible. Irreversible death means that no
known as the dead donor rule. This was developed in matter what interventions are made, the patient will
the 1960s to clearly state that organ procurement must still be dead. Permanent death is death that applies
always come after, and not cause, a patient’s death. to that person, not to the possible recoverable func-
Cardiopulmonary death is defined as simultaneous tion of an individual organ. In this argument, if a
and irreversible unresponsiveness, apnea, and absent person has chosen not to be resuscitated, then death
circulation. The heart must stop beating. Patients who after withdrawal of life-sustaining therapies is in fact
are dead by neurological criteria are declared dead be- permanent and will progress to irreversible. The fact
cause they no longer have any brain function, even that organs can function after removal and trans-
though they may still have a heartbeat when kept on plantation does not alter the fact of the donor indi-
a ventilator. If the ventilator is removed, they will not vidual’s death. They further argue that NHBOD is
breathe, and the heart will stop soon after. The patient ethically permissible during the second period, the
may not die because the heart or other vital organs period of permanent but not necessarily irreversible
have been removed. The crux of the ethical debate on death (50). They agree that organ procurement dur-
this issue centers on the ambiguity of irreversibility in ing the time period where autoresuscitation is possi-
this scenario. A patient who has a cardiac arrest and ble is not permissible.
does not undergo CPR will die. If the patient in the To standardize practice and to address these ethi-
next bed has a cardiac arrest and does undergo suc- cal concerns, several professional organizations have
cessful CPR, he or she will live. One could argue that created recommendations for the ethical practice of
the first patient might not be irreversibly dead, yet very NHBOD. These groups include the Institute of
few ethicists would require that this patient be resus- Medicine (51), the American College of Critical
citated if she or her family/surrogates had chosen that Care Medicine (52), and the American Society of
she be allowed to die. Transplant Surgeons (53). They make specific recom-
In 2008, The New England Journal of Medicine de- mendations regarding the waiting period between the
scribed several examples of pediatric cardiac trans- onset of unresponsiveness, apnea, and absent pulse
plant after NHBOD (48). In this article, three infants and organ procurement; care of the dying patient
were non–heart-beating organ donors. Declaration of who may be a donor; and care of the patient’s family.
death occurred between 75 and 180 seconds after the This debate will continue, however, because organs
cessation of cardiac circulation. In all three recipients, remain in shortage and society continues to grapple
the heart was restarted, and all three recipients were with the best ways to meet the ongoing demand.
alive at 6 months. Many readers of this report felt that Clinical medicine and clinical research are both
this was an example of violation of the dead donor guided by principles of bioethics. Because of their
rule, as the heart was not irreversibly stopped. There professional skills at providing life-sustaining thera-
was particular focus on the last two cases in which the pies such as MV, RTs are likely to encounter ethically
period of asystole was shortened to 75 seconds. complex clinical situations. Bioethics offers a way to
The length of asystole has particular importance think about not only what can be done for a patient,
because it speaks to our uncertainty regarding but also what ought to be done.
2831_Ch20_503-524 13/03/14 3:35 PM Page 521
high-frequency oscillatory ventilation. Lucy’s cur- for ECMO? Based on the prognosis for near-
rent ventilation settings are as follows: frequency drowning and Lucy’s current clinical picture,
of 5 hertz, change in pressure (␦P) of 65 mm Hg, do you think she meets the criteria for
mean airway pressure of 33 mm Hg, inspiratory- ECMO?
time of 33%, FIO2 of 1.0. Her last blood gas was
The pediatric intensivist explains Lucy’s recent
pH, +7.32; partial pressure of carbon dioxide,
progress to her parents as well as the likely
+48 mm Hg; partial pressure of oxygen,
progression over the next few hours and days.
+55 mm Hg; and HCO3, +24.4 mEq/L.
ECMO is explained as a treatment option. The
• What is Lucy’s oxygenation index? intensivist describes the merit of using ECMO
• What are some advanced respiratory thera- as such: “ECMO will not heal Lucy’s lungs. It
pies that could potentially improve Lucy’s may not make things better, and it can certainly
oxygenation? make things worse. And I do not know if it will
work or not. But it can buy us some time to
Lucy initially presented with atrial fibrillation,
figure out how to resolve the lung problems that
which has subsequently resolved, but throughout
Lucy is having without resorting to really aggres-
the last 18 hours, the pediatric intensivists have
sive ventilator strategies, which may be causing
been struggling to maintain an adequate blood
or contributing to her recent blood pressure in-
pressure. Despite starting and titrating dopamine
stability.” Lucy’s parents would like the PICU
and dobutamine drips, Lucy’s blood pressure is
team to “try everything” to heal Lucy’s lungs.
consistently maintaining around 86/42 mm Hg
The PICU intensivist will activate the ECMO
(mean = 55.3 mm Hg). A family meeting is called
team and estimates that Lucy will be on ECMO
with the parents, grandparents, bedside nurse,
within 1 hour.
nurse manager, pediatric intensivist, ECMO coor-
dinator, and RT. The discussion will clarify the • Should an ethics committee be called in be-
cardiopulmonary issues that Lucy is now having. fore Lucy is cannulated and placed on ECMO?
Decisions need to be made by the family in collab- If someone on the team does not agree with
oration with the team regarding the next steps in this decision, can the parents’ decision be
Lucy’s care, including whether to pursue ECMO. overridden?
• What is it about Lucy’s diagnosis and pre-
sentation that could make her a candidate
Multiple-Choice Questions
1. The four ethical principles that guide much of 3. Interventions that can prevent medical errors
modern bioethics include: include:
I. Justice. a. Computerized medical records.
II. Autonomy. b. Work duty hour limits.
III. Fidelity. c. Patient education.
IV. Veracity. d. Visibly marking surgical sites before the
V. Compassion. procedure.
VI. Informed consent. e. All of the above.
VII. Beneficence. 4. During a public health emergency, clinicians
VIII. Nonmaleficence. may have a duty to:
a. I, II, IV, VI I. Report to work.
b. II, III, IV, V II. Comply with mandatory vaccination.
c. I, II, VI, VII III. Suspend professional autonomy and
d. I, II, VII, VIII engage in resource allocation.
2. In health care, the principle of justice refers to: IV. Not discuss resource limitations with
a. A patient’s right to equal access to medical patients.
care. a. I, II, III, IV
b. Holding health-care providers accountable b. I, II, III
for errors made. c. I, III, IV
c. A patient’s right to make decisions based on d. I, II, IV
his or her personal values.
d. Providing care that is not harmful to the
patient.
2831_Ch20_503-524 13/03/14 3:35 PM Page 523
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12. Institute of Medicine. To Err is Human: Building a Safer or treatment on the basis of claims of conscience. Pedi-
Health System. Washington, DC: Committee on Quality atrics. 2009;124(6):1689-1693.
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Emergency Health Powers Act: planning for and response type I spinal muscular atrophy in North Dakota. Am J
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Chapter 21
Palliative and
End-of-Life Care Wynne Morrison, MD, MBE
525
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Chapter Objectives
After reading this chapter, you will be able to:
1. Describe the role of the respiratory therapist in helping families with difficult pediatric end-of-life
decision-making.
2. Discuss the range of reasonable decisions possible for a family deciding how to best care for their child
with a life-threatening illness.
3. Explain the balance of burden and benefit in determining what respiratory support to offer at the
end of life.
4. Outline the process of creating a “do not attempt resuscitation” order.
5. Describe at least two different approaches to discontinuing mechanical ventilation) at the end of life.
6. Name at least two nonpharmacological strategies for the treatment of dyspnea at the end of life.
7. Name three members of the palliative-care team and their respective roles.
8. Discuss the uses and side effects of narcotic and sedative agents at the end of life.
9. Help a family determine the ideal location of death, depending on the patient’s and family’s
circumstances.
10. Discuss the services that are typically available from hospice agencies to support dying at home.
11. List five ways that the team can help support a family at the time of a patient’s death.
12. Describe vital components of end-of-life care, including self-care and team support.
Michael Simpson
M
■■ odern medicine has been able to cure many
diseases. Health-care professionals are
Michael is 4 years old and has myotubular myopa- able to save the lives of many children and
thy, a genetic disorder of muscle function, leading relieve much suffering for patients who would have
to profound weakness of his face, extremities, and died at an early age even a few decades ago. Many
respiratory muscles. His disease was diagnosed of these life-saving interventions involve the support
at a few months of age, when he was not rolling and treatment of respiratory failure, whether by me-
himself over or sitting when it would normally be chanical ventilation (MV), secretion-management
expected. He cannot be fed by mouth owing to dif- modalities, or even extracorporeal support until the
ficulty swallowing and frequent choking, so he has cause of respiratory failure is either treated or stabi-
had a gastrostomy tube placed. Since the age of lized. Some children are able to recover from critical
8 months, he has required noninvasive positive- illness, or even repeated episodes of such illnesses, to
pressure ventilation (NIPPV) for 18 to 20 hours a go on to lead happy, productive lives. Modern tech-
day, but he has been cared for predominantly at nology has also allowed health-care professionals to
home with frequent rehospitalizations for infections stabilize many children with chronic illnesses, help-
requiring an escalation of his respiratory support. ing them to live much longer lives than they would
He has been intubated for pneumonia three times have in the past, even when the disease cannot be
in the past 2 years, each time spending 2 to cured. With careful medical management, many chil-
4 weeks in the intensive care unit (ICU), and he has dren with diabetes, cystic fibrosis, congenital heart
now been readmitted with an adenovirus infection. disease, or other chronic conditions can do very well.
For the past several days, he decompensates rap- There are other conditions that can be very difficult
idly if taken off of positive pressure for even a few to manage, however, because they are likely to be life
minutes, and he requires aggressive interventions limiting. Children with these conditions often do not
from the respiratory therapy team on an almost survive with a good quality of life into adulthood, yet
hourly basis to help with his secretion clearance. health-care professionals are able to manage the life-
This includes suctioning, adjusting his bi-level threatening complications that arise so that there is
positive airway pressure device (BiPAP) interface, much uncertainty regarding whether or not death is im-
giving nebulized medications, and using a cough- minent. Even when faced with an illness for which the
assist device. You and his mother have just spent medical team is almost certain that short-term survival
45 minutes together at his bedside administering is not possible, such as with cancer that is no longer
his treatments, and she turns to you and asks responding to treatment, health-care professionals
whether you think this is too much to put him are still faced with decisions regarding the possibility
through. of using life-sustaining technology. These decisions
are difficult because although such technology may
2831_Ch21_525-544 13/03/14 3:44 PM Page 527
Table 21-1 Palliative-Care Teams Are Comprised of Individuals From a Variety of Disciplines, Some
Noted Here. Individual Team Structures Vary.
Discipline Role
Physician/nurse practitioner Assess and prescribe medications to treat pain and suffering; assist patients
and families with decision-making; write orders to limit resuscitation
Nurse coordinator/case manager Interface with insurance companies and hospice agencies to organize appro-
priate patient care and family support
Social worker Interfaces with insurance companies and hospice agencies to organize appro-
priate patient care and family support; counsels patients and families on finan-
cial and psychosocial issues; provides bereavement support
Chaplain Provides spiritual support to patients and families and coordinates specific
religious rituals when desired
Child life therapist/art therapist/ Work with patients and siblings to process distressing circumstances in a non-
music therapist threatening manner; provide memory-making activities and family support
around the time of a child’s death
Psychologist Provides support and counseling to patients and families and referrals to
broader mental health support when needed
Bereavement coordinator/grief Organize hospital services or memorials for families; provide resources or
counselor referrals to counseling and support groups for families
Usually From an Outside Agency
Hospice medical director Works with team to manage patient’s symptoms at home
(hospital physician will often
function in this role for children)
Hospice nurse Provides phone and in-home support for patients and families to manage
symptoms and facilitate remaining at home; usually may declare death at home
Hospice volunteer/nurse’s aide Assist with patient care needs at home
The hospice agency may also have its own social worker, chaplain, counselors, and bereavement support.
2831_Ch21_525-544 13/03/14 3:44 PM Page 528
■ ■ You tell Michael’s physicians and nurses about In fact, recent health-care reform legislation includes
the questions his mother is raising, and a meeting is a provision that children whose health care is funded
arranged with both parents the following day. The by Medicaid or by the Children’s Health Insurance
ICU attending physician, primary nurse, and you are Program (CHIP) be eligible for simultaneous cura-
all able to attend the meeting. During the discussion, tive and palliative interventions, including hospice,
Michael’s parents confide that they worry that with by 2013 (8). Many private insurers are beginning to
each illness he requires so many interventions to offer similar benefits. The advantage of encouraging
help him handle his secretions and avoid plugging early referrals and allowing concurrent care is that
that he is often uncomfortable and agitated. Yet it avoids artificially forcing a family to make a diffi-
when he is at home and doing well, they feel that he cult choice between supportive services and ongoing
is happy, comfortable, and loves interacting with his treatments.
family and watching movies. After much discussion, It is also important to realize that intubation, ven-
the decision is made to intubate Michael if needed. tilation, and tracheostomy are not necessarily in-
Everyone hopes that he can return to baseline fol- compatible with a palliative approach. There are
lowing this illness, but the medical team will reassess some situations in which intubation and sedation
whether this outcome seems likely as events evolve. might be more comfortable for a patient than trying
The Simpsons also worry that he is often fright- to avoid intubation. In Michael’s case, for example,
ened when strangers come into the room, and his it might be much easier to manage his secretions if
mother feels she can never leave his bedside. The he is intubated, and the team might be more willing
team suggests posting signs at the bedside to make to give him medications that will sedate him because
sure all staff members realize that Michael is cogni- they are less worried about suppressing his already-
tively intact and alert. They plan to encourage every- weak cough. He may be able to be more easily fed
one to talk to him and prepare him before starting once intubated, and he would not have to be awak-
any procedures or therapy. They also decide to allow ened hourly for chest physiotherapy. Yet, he is also
his dog to visit him in the hospital to attempt to im- likely to be fairly difficult to wean from the ventila-
prove his mood. In addition, the attending physician tor and could require intubation for weeks. Simi-
tells the family about the palliative-care team at the larly, a tracheostomy sometimes makes sense for
hospital (“a team that helps to support many families a patient who is approaching the end of life if it
whose children have life-threatening conditions”) and allows a significant amount of remaining quality
says that she plans to call this team so they can get time for the patient without the discomfort of an
to know Michael and his family. endotracheal tube (ETT). The advantages of such
procedures always need to be weighed against the
disadvantages, with consideration of whether the in-
tervention promotes a high quality of life or pro-
Early Referral/Concurrent Care longs suffering.
Michael’s case is a good illustration of trying to
Initiating palliative care should not wait until a de- consider ways to improve his life—educating the
cision is made not to escalate or to withdraw inter- staff, letting him see his pet—even while he is under-
ventions. It is possible to focus on comfort and going aggressive interventions. His physician intro-
quality of life even while continuing potentially ag- duced the palliative-care team in a positive way, as
gressive disease-focused or curative therapies. In a group who could help support Michael and his
hospitals where there is a specialized palliative-care family, without making it seem that their only role
team, it can be helpful for the team to get to know a is to care for children who are imminently dying.
patient and family early so that they may provide Some families also need reassurance that a palliative-
support and build an alliance even before difficult care team will work alongside rather than replace the
decisions need to be made. Doing so usually allows other providers (e.g., oncologists, pulmonologists)
the development of a better relationship than that with whom the family already has a close relation-
which occurs when patients and families meet the ship. It is also good practice to promote team com-
team for the first time right after making a decision munication by having the nursing and respiratory
not to escalate or to withdraw therapies. therapy staff members attend the family meeting.
There is a growing recognition that concurrent The nurses and therapists can be very helpful in rais-
care, or the simultaneous pursuit of both palliative ing concerns they have about what is difficult for the
and curative measures, benefits most patients (7). patient. Having everyone participate in the discus-
Whereas in the past patients were required to forego sion and formulation of a plan presents a consistent
therapies with curative intent (e.g., chemotherapy) message to the family. It is common for a family to
in order to enroll in hospice, many payors are begin- ask the bedside nurse or therapist for their interpre-
ning to see the benefits of allowing more flexibility. tation of what the doctor said following a meeting.
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(Select interventions that will not be performed in the event of respiratory or cardiac arrest):
Non-invasive ventilation
Manual positive pressure ventilation
Intubation
Mechanical ventilation
Inotropic medications
Chest compressions
Defibrillation
I (have/have not) discussed this decision with my relatives and friends, describing the nature and justification for my decisions.
My physician, , has explained to me the nature of resuscitative measures, their risks and
benefits, and the risks and benefits of refusing such interventions. I have had an opportunity to ask questions, and have had all of
my questions answered by my physician.
After careful consideration of all I discussed with my physician, I request to forego the above-selected attempts at resuscitation.
Name:
Signature:
Date:
Time:
Witness:
Date:
Time:
Table 21-2 Overall Success of Resuscitation from a medical standpoint. The use of the phrase
Following Cardiopulmonary Arrest “some families choose” may have helped the family
for Each Group in Published realize that multiple options were available and
Studies (13-20) that reasonable families could choose any of those
options. The physician guided them toward setting
Range of Survival to Hospital Discharge limits on resuscitative efforts if Michael had a car-
Population Out-of-Hospital Arrest In-Hospital Arrest diac arrest, presumably because resuscitative ef-
Adult 3%–16% 6%–22% forts were unlikely to be successful when advanced
ventilatory support and vasoactive medications
Pediatric 4%–16% 27%
were already in place. Although it was clear that
the family had the ultimate decision, the physician
provided them with medical expertise to help them
conversations to avoid presenting a list of possible make that decision.
interventions and then asking them to say yes or no Families will occasionally ask health-care providers
to each one. The family conversation should focus for their opinion about the best course of action. How
instead on the overall goals of care (e.g., comfort, would you handle the question, “If this was your
prolonging life if at all possible, a time-limited trial child, what would you do?” (21, 22). Providing an
of an intervention to see if there is a response), and opinion can be helpful—and is preferable to leaving
the medical team can then determine what specific a family feeling that they have to take the burden of a
interventions meet those goals. decision entirely on their own shoulders—but it
In Michael’s case, the attending physician was should be done in way that does not assume they
offering his family a choice between several alter- share your values or that there is only one acceptable
native paths, each of which would be reasonable choice in the circumstances (Box 21-1) (23–25).
2831_Ch21_525-544 13/03/14 3:44 PM Page 533
Box 21-1 Examples of Useful Phrases to with a tracheostomy at home to make sure they
Support a Family Making Difficult understand what is involved, but the Simpsons
Decisions still agree that it is not what they want for Michael.
The team therefore plans one more extubation at-
“I know these are difficult discussions to have. tempt but decides that, if he fails, he will not be
But I can tell that you are working very hard to reintubated.
really think about what is best for your child.”
“In situations like this, I have seen loving fam-
ilies that choose different paths depending on Discontinuing Mechanical Ventilation
what life has been like for their child recently.
Do you want me to talk about what some of Michael’s case is different from that of some
those options might look like?” children for whom MV is discontinued because there
“I wish that your child was not in this situa- is a moderately good chance that he could survive the
tion and that there were therapies that we had extubation because he is on low ventilator settings.
to offer to make it better. We will continue to It is therefore very important to prepare the family
do everything we can think of to take the best for a range of possible outcomes of the extubation—
possible care of him. But considering that it may he could breathe adequately with NIPPV (if all agree
not be possible to cure his disease at this point, to provide this) and potentially be discharged home.
we also need to think about how to make sure However, it is also possible that he will struggle to
that we do not make him suffer any more than breathe and require medications to help him be com-
necessary.” fortable. Yet, even in this scenario, he could live for
“Tell me about your child and what is impor- hours to days following the extubation. It is therefore
tant to him.” important to avoid being overly certain in predicting
“You can really help us in this situation by let- a time from extubation to death, even for the sickest
ting us know what life is like for him when he is patients.
doing well and is not in the hospital. We only get In Michael’s case, the weaning of his ventilator to
to see him when he is ill. You know him best and extubation would likely be fairly standard, and med-
can best tell us what quality of life he has.” ications for dyspnea would be provided only if he
“Given everything that we have discussed, demonstrated that he needs them. When a ventilator
I have some thoughts about which of the medical is being discontinued for a patient on higher settings
interventions we have to offer are most likely to be with an expected inability to survive, it is important
useful in your child’s situation. Would it be helpful that there is a plan in place to ensure patient comfort
to you for me to make a recommendation about during the process (26). Removing the ETT may im-
what I think might be the best path forward?” prove comfort, but the loss of positive pressure may
worsen work of breathing (WOB). If medications for
For more examples, see essay by Dr. James Tulsky on communication (23).
comfort are going to be used, discuss with the team
whether doses should be given or infusions started
or increased prior to discontinuing the ventilator.
■ ■ Michael improves following his episode of sepsis, The specific pharmacological treatment of dyspnea
and again his ventilatory support is able to be weaned is discussed later in this chapter.
over a 4-week period. Despite being on extubatable
settings and daily “sprinting” exercises to continuous Terminal Extubation Versus
positive airway pressure (CPAP) and pressure sup- Terminal Weaning
port, he fails an extubation attempt to NIPPV because
There are two commonly used approaches to discon-
of weakness. He has been in the ICU for more than
tinuing MV in a patient expected to die: terminal
3 months now, and the team begins discussions
extubation and terminal weaning (27, 28). With
with the family regarding the possibility of a tra-
terminal extubation, the ventilator is discontinued
cheostomy to provide ongoing mechanical support
and the ETT removed without weaning the venti-
of his breathing.
lator prior to doing so. This technique is often ap-
After a few days of considering what has been
propriate for a patient who is heavily sedated or
said, Michael’s parents tell the team that they would
obtunded and therefore not expected to experience
not want to proceed with a tracheostomy. They feel
much respiratory distress when the ventilator is dis-
that Michael’s activities would be so limited by being
continued. Terminal weaning is a method of slowly
constantly ventilated with likely repeated hospitaliza-
lowering ventilatory support over a period of hours
tions that he would lose much of his enjoyment in
(or days, in the early descriptions) prior to removing
life. They meet with another family who has a child
the ETT. Depending on the situation, some degree
2831_Ch21_525-544 13/03/14 3:44 PM Page 534
of weaning the ventilator may offer the advantage Increased WOB, color changes, noisy breathing, and
of assessing how comfortable the patient is with increased secretions can all be anticipated. Family
lower ventilatory pressures and oxygen supplemen- members can be reassured that any signs of distress
tation prior to removing the ETT, which would will be treated, but if they are bothered by unusual
allow the escalation of sedatives or narcotics as breathing patterns such as stridor or agonal breaths,
needed beforehand. Weaning also has a theoretical they can be reassured that this is a normal occur-
benefit of allowing the retention of carbon dioxide rence and that their child is not alert or suffering.
prior to the extubation because severe respiratory Staff members should check in frequently following
acidosis can have a sedative effect. Unfortunately, an extubation to make sure that the child is comfort-
respiratory acidosis usually causes marked agitation able and that the family feels supported. Turning off
until the partial pressure of carbon dioxide (PCO2) monitors and following vital signs from another
rises significantly, so this is rarely a true benefit of monitor outside the room can minimize disturbances
slow weaning. Treating respiratory distress with in the room.
medications is a better option. Slow weaning also
has the disadvantage of delaying the extubation at a Organ Donation
time when the family is likely ready to have the ven- Prior to withdrawing MV, it is important to assess
tilator removed as soon as possible. A few minutes whether organ donation following cardiac death can
at lower settings is almost always enough to assess be offered to the family. Most organ donation oc-
whether the patient is comfortable and if the use of curs following a neurological determination of death
medications is needed. If a patient is being extubated (“brain death”), in which case the ventilator does not
from an advanced mode of ventilation such as need to be discontinued prior to organ procurement
HFOV, it might be helpful to offer the family the because the patient has already been declared dead.
possibility of switching to conventional ventilation For patients who are not brain dead but are expected
prior to the extubation so that they can hold the to die within 1 hour following discontinuation of
child before or while the ETT is removed. ventilation, it may still be possible to donate after
death is declared using cardiopulmonary criteria
Preparing the Family (see Chapter 20 for an in-depth discussion). Some
Prior to an extubation, the team should formulate disease processes, often infections or disseminated
a plan for the logistics of the process. The team cancer, will prevent a patient from being a donor.
should decide beforehand about whether other med- Exploring these questions proactively with the local
ical equipment, such as nasogastric tubes, central organ-procurement organization prior to the extu-
lines, and intravenous (IV) tubes or catheters, will be bation is useful to determine if there is a possibility
removed at the same time. Maintaining some form of offering this procedure to the family.
of IV access can be useful for administering medica-
tions to treat distress. Many families will want to be
present if possible for the extubation, but they ■ ■ Michael’s parents ask to extubate him the day
should not be forced to be at the bedside if they are after the family meeting so that arrangements can be
more comfortable waiting elsewhere. Some families made to have his grandparents present as well. As
have cultural or spiritual traditions that they would there is a chance that Michael will survive his extuba-
like to follow prior to the withdrawal. Families may tion, his family is preparing for all possibilities. They
need time to gather or prepare relatives. Some family have decided to continue to use his BiPAP, which is
members prefer to hold their child or lie in bed with reasonable because it is a baseline level of support
their child at the time of extubation. It is helpful to for him. The team has planned with his parents that
ask the parents directly how many other family they would not increase his BiPAP pressures above
members they would like to have present so that the his usual home baseline to avoid adding possible
team can help control how crowded a room gets if discomfort caused by using high pressures and
the parents prefer privacy. Conversely, some relax- the need for a tighter-fitting mask. They decided
ation of limits on the number of visitors that can be together, however, that they could use a higher FIO2
present is also helpful for many families who benefit than his baseline, at least temporarily, by using the
from the support of extended family members. Mov- ICU ventilator rather than his home BiPAP machine.
ing the child to a private room prior to the extuba- The rationale was that the higher FIO2 should not
tion, if one is available, is often helpful to give a cause discomfort and would, it is hoped, help him
grieving family privacy, avoid distressing other fam- make a transition back to his home level of support.
ilies that might be present in the unit, and help staff If his home pressure settings are not enough to treat
focus on the needs of the dying child. his dyspnea, the plan is to increase his pharmacolog-
Families should also be prepared for what their ical treatment of breathlessness until he is comfort-
child might look like when the tube is removed. able. An RT who has recently finished orientation has
2831_Ch21_525-544 13/03/14 3:44 PM Page 535
responsibility for his care for the day and asks you to Supplemental oxygen
help because he has never removed a ventilator from
• Does it make the patient
someone who may die following its discontinuation. more comfortable?
When the team and family are ready, you and • Is there anything about it
the new therapist, along with one of the physicians, that is bothersome to the
patient?
remove Michael’s ETT. He has a very shallow respi- • Am I treating the
ratory effort. He is placed quickly onto his nasal numbers (improving the
mask BiPAP interface with his home settings (end- SpO2), or the patient?
expiratory airway pressure [EPAP] of 6 and inspira-
tory positive airway pressure [IPAP] of 15) with
Environmental
100% oxygen supplementation. His oxygen satura- changes Nebulized
tions then improve from the 70s to the low 90s, medications
• Open a window
and his WOB is improved, but he continues to look • Music Dyspnea • Lidocaine
somewhat anxious and distressed. His family asks • Provide a calm • Bronchodilators
environment
if it is time to give him medication for comfort.
on medications that may be useful when respiratory these medications are abruptly discontinued or
symptoms are severe and will cover various narcotic weaned too rapidly. Symptoms can include agita-
and sedative agents. In addition, the nebulized delivery tion, sweating, tachycardia, fever, tremors, yawning,
of medications will be briefly addressed because RTs vomiting, and diarrhea. Specific care should be taken
may be involved in administering medications by this in pediatrics when using combination agents (an opi-
route. oid combined with acetaminophen, for instance);
dose escalation of the opioid may become necessary
Opioid (Narcotic) Medications for severe pain, but escalating could lead to toxicity
Opioid or narcotic agents are usually the first-line and organ injury from the other agent. It is usually
therapy for the treatment of dyspnea or pain at the better, therefore, to dose opioids separately from
end of life (30). There are many formulations avail- acetaminophen or nonsteroidal anti-inflammatory
able, including IV medications given by infusions or agents to avoid this problem.
as bolus doses, oral liquids or pills, sublingual or
transdermal (patch) preparations, and agents for Rule of Double Effect
rectal administration. For those able to take tablets The respiratory-depressant effect of opioids is partic-
or capsules, oral preparations are available in both ularly worrisome to clinicians who use them to treat
immediate and sustained-release formulations. Sub- pain because they are concerned about causing or has-
cutaneous infusion catheters can be used in patients tening death by increasing doses. The “rule of double
who are unable to take adequate doses of medication effect,” which is covered in depth in Chapter 20, jus-
by mouth, but in whom maintaining IV access is tifies the use of opiates to treat severe pain, even if
either difficult or burdensome (31). they do lead to respiratory depression. In patients
All opioids have effects at the μ-opioid receptor who are not expected to die, the respiratory depres-
in the central nervous system (CNS) to cause anal- sion can be managed by lowering doses, using reversal
gesia (pain control), euphoria, and cough suppres- agents, or providing MV if needed. In patients who
sion. They also have predictable side effects such as are expected to die, it is possible that medications
suppression of the drive to breathe, itching, nausea, might hasten death, but this risk is justified by the im-
constipation, and urinary retention. Side effects can portance of treating pain and dyspnea. In reality, cli-
end up causing almost as much distress as the symp- nicians are rarely confronted with a choice of this
toms one is attempting to treat, so anticipation and nature. If medication doses are increased incremen-
treatment (e.g., a laxative regimen for constipation) tally until pain is controlled, they are highly unlikely
are important. Changing from one agent to another to cause respiratory depression because the pain itself
can sometimes both decrease side effects and im- is a powerful respiratory stimulant. Eventually, doses
prove pain control. Duration of action of the nar- much higher than the maximum recommended start-
cotics varies notably, with the more lipid-soluble ing dose are commonly necessary, especially in pa-
drugs, such as Fentanyl, having very short half-lives. tients who have been receiving these medications for
Morphine is longer acting, but because it leads to a some time. There is no upper limit on doses that can
release of histamine, it may cause more itching than be administered, as long as the beneficial effects and
other narcotics. It can also cause bothersome neuro- side effects are balanced. Studies in adult patients at
logical toxicities such as myoclonus (involuntary the end of life have shown, perhaps surprisingly, that
muscle twitches) when used at high doses for long those who receive the highest doses of narcotic and
periods, particularly in patients with multiorgan fail- sedative agents often survive the longest following the
ure (32). Hydromorphone and oxycodone are useful withdrawal of life-sustaining therapies (33), suggest-
alternatives if unmanageable side effects occur. ing that it is rare that these agents hasten death
Codeine can be particularly problematic because it in usual practice. Even in neonates, high doses of
is not effective until it is metabolized to morphine, narcotics—when appropriately titrated for control of
and 10% of people are unable to metabolize it (30). symptoms—are not associated with time to death
In those patients, it can cause severe nausea without (34). Underdosing of pain medications at the end of
the benefit of pain relief. Meperidine should also be life is unfortunately far more often a problem than
avoided because a metabolite can accumulate that overdosing (35).
has been reported to cause seizures in both adults
and children. Methadone has a very long half-life Nebulized Medications
that can make dosing adjustments difficult, but it has Nebulized medications such as morphine have been
the advantage of NMDA receptor effects that some- studied in an attempt to determine if this route of
times help with neuropathic pain and has added ben- administration provides relief for subjective feelings
efits in patients who are opioid tolerant. Tolerance of breathlessness without the side effects and respi-
can develop over time to all opioids, requiring an ratory depression that are seen with systemic admin-
escalation of doses. Withdrawal symptoms occur if istration of narcotics (36). Although case reports and
2831_Ch21_525-544 13/03/14 3:44 PM Page 537
Multiple-Choice Questions
1. A 14-year-old boy has sustained severe injuries Reasonable courses of action include the
after being struck by a car. Two days after the following:
injury, his parents state that “he would never a. Intubate him because his mother requests it.
want to be hooked up to machines” and ask b. Attempt to discuss the situation with the pa-
that the ventilator be discontinued. In what tient and determine if he is able to express
circumstances is it possible to do so? his wishes in the current situation.
a. The patient would have to be “brain dead” c. If the patient is unable to communicate, sta-
to remove the ventilator. bilize him with noninvasive ventilation while
b. A judge would have to order the removal of attempts are made to reach his boyfriend
the ventilator. who is the legal decision-maker.
c. The parents and medical team would have d. Call his father to ask him what he wants
to agree that the prognosis was poor enough done.
that continuing ventilation carried more e. b or c
burden than possible benefit. f. a or d
d. The parents’ request alone is sufficient and 4. A 12-year-old with relapsed leukemia, sepsis,
must be honored. and multiorgan failure is mechanically venti-
2. Which of the following terms refers to care lated and on high doses of a norepinephrine
that is focused on relieving the suffering of infusion. Her parents meet with the oncology
patients? team and decide to place a do not attempt re-
a. Hospice care suscitation order because it is highly unlikely
b. Curative care that she will be able to survive. The appropri-
c. Palliative care ate next step is to:
d. Concurrent care a. Extubate her because she is now DNAR.
3. A 24-year-old young man with cystic fibrosis b. Ask for clarification from the physician who
still receives his care at the pediatric center. had the conversation about whether current
He has a legally documented advance directive interventions are going to continue and
naming his boyfriend as his decision-maker whether medical care will be escalated if a
and stating that he does not want to be intu- cardiac arrest does not occur.
bated for an acute event. He is brought to c. Stop assessing her for wheezing and the
the emergency department by his mother in need for PRN albuterol doses because other
respiratory distress from pneumonia, and she patients will benefit more from your time at
demands that he be placed on a ventilator. this point.
2831_Ch21_525-544 13/03/14 3:44 PM Page 542
5. A 6-year-old has a progressive brain tumor c. Facilitate comfort and family support so
that has led to respiratory failure. His parents that a patient can remain home and avoid
have accepted the physician’s recommendation unwanted medical interventions at the end
to have him extubated so that they can focus of life.
on his comfort at this time. In preparing to d. Consult with the hospital to obtain a do not
discontinue the ventilator, you lower the FIO2, attempt resuscitation order on a patient.
and he becomes cyanotic and anxious with 9. You walk into the room of a 9-year-old girl
wide, frightened eyes. An appropriate course with end-stage cancer to perform chest physio-
of action would be to: therapy. She is sleeping, but her mom asks if
a. Remove the tube quickly to see if he is more you have a few minutes to talk about whether
comfortable. you think any of the respiratory treatments
b. Increase the FIO2 temporarily and ask for ordered for her daughter are “worth it.” What
additional medications so that he is comfort- strategies can you use to help you respond to
able prior to discontinuing the ventilator. this request?
c. Tell his parents that you think he will strug- a. Offer to get the physician or bedside nurse
gle far too much if the ventilator is discon- to discuss these issues.
tinued and suggest that they pursue a b. Pause in what you’re doing and give your
tracheostomy instead. full attention to the mom.
d. Ask that he receive a dose of paralytic prior c. Do not allow the conversation to go on too
to the extubation so that his WOB is not long and distress the family.
distressing to his parents. d. Recommend to the mom a plan of changes
6. Which of the following are options for parents to the respiratory order.
during a terminal extubation? 10. You are a home-care RT and receive a call
a. Holding the child while you extubate from a father whose 4-year-old son, James, is
b. Complete a religious service before or during receiving oxygen via nasal cannula as part of
the extubation his hospice care. Dad called because James is
c. Wait in a family waiting room during the looking more short of breath, and he was wor-
extubation ried that perhaps the oxygen equipment isn’t
d. Any of the above are options that should be working correctly. You will come out to visit
offered to the family. to be sure everything is working; what other
7. Narcotics (opioids) can cause the following things can you suggest for James to improve
signs or symptoms except: his dyspnea?
a. Diarrhea I. Albuterol
b. Relief of air hunger II. Quiet, calming environment
c. Relief of pain III. Fan
d. Itching IV. Sedative
e. Nausea V. Increase oxygen
8. Hospice agencies typically: VI. Noninvasive ventilation
a. Provide 24-hour nursing care and rehabilita- a. I, II, III, IV
tion services for a patient going home on a b. II, III, IV, V
ventilator. c. I, IV, V
b. Provide insurance coverage for a patient who d. II, III
is not eligible for Medicare or Medicaid.
43. Feudtner C, Feinstein JA, Satchell M, et al. Shifting place 47. Meyer EC, Burns JP, Griffith JL, et al. Parental perspec-
of death among children with complex chronic conditions tives on end-of-life care in the pediatric intensive care unit.
in the United States, 1989-2003. JAMA. 2007;297(24): Crit Care Med. 2002;30(1):226-231.
2725-2732. 48. Borasino S, Morrison W, Silberman J, et al. Physicians’
44. Feudtner C, Kang TI, Hexem KR, et al. Pediatric pallia- contact with families after the death of pediatric patients: a
tive care patients: a prospective multicenter cohort study. survey of pediatric critical care practitioners’ beliefs and
Pediatrics. 2011;127(6):1094-1101. self-reported practices. Pediatrics. 2008;122(6):e1174-e1178.
45. Meert KL, Briller SH, Schim SM, et al. Examining the 49. Eggly S, Meert KL, Berger J, et al. A framework for con-
needs of bereaved parents in the pediatric intensive care ducting follow-up meetings with parents after a child’s
unit: a qualitative study. Death Stud. 2009;33(8):712-740. death in the pediatric intensive care unit. Pediatr Crit Care
46. Lanctot D, Morrison W, Kock KD, et al. Spiritual dimen- Med. 2011;12(2):147-152.
sions. In: Carter BS, Levetown M, Friebert SE, eds. Pallia- 50. Serwint JR. One method of coping: resident debriefing
tive Care for Infants, Children, and Adolescents: A Practical after the death of a patient. J Pediatr. 2004;145(2):229-234.
Handbook. 2nd ed. Baltimore, MD: Johns Hopkins 51. Luce JM. End-of-life decision making in the intensive care
University Press; 2011:227-243. unit. Am J Respir Crit Care Med. 2010;182(1):6-11.
2831_Glossary_545-562 13/03/14 3:42 PM Page 545
Glossary
A Airway hyperresponsiveness: exaggerated bron-
Accelerations: increase in fetal heart rate, associ- choconstrictor response to a wide variety of
ated with fetal movement; a sign of fetal stimuli; a major feature of asthma.
well-being. Airway pressure release ventilation (APRV): alter-
Acinar unit: lung unit consisting of a respiratory native mode of ventilation that couples a high
bronchiole, alveolar ducts, and alveolar sacs. continuous airway pressure and intermittent
Activated clotting time (ACT): bedside laboratory time-cycled release to augment the patient’s
test that detects how fast blood will begin to clot spontaneous ventilation.
once a sample is taken from an extracorporeal Airway remodeling: caused by both the inflamma-
life support circuit and introduced into the tion and repeated and continuous incidences of
device; usual ACT is 180 to 220 seconds. bronchoconstriction. These permanent changes
Active cycle of breathing (ACB): basic breathing in the airway can increase obstructions and de-
exercise that cycles through three types of crease responsiveness and can cause a patient
breathing: diaphragmatic breathing, thoracic to be less responsive to therapy.
expansion, and forced expiratory technique. Airway resistance: friction that occurs between
Active phase: period during labor when cervix moving molecules in the gas stream and between
dilates to approximately 8 to 9 cm; time of the these moving molecules and the wall of the
most rapid cervical dilatation. respiratory system.
Acute lung injury: umbrella term used for lung Allergic bronchopulmonary aspergillosis (APBA):
damage displaying hypoxemic respiratory fail- fungal infection within the lungs, characterized
ure, characterized by bilateral pulmonary infil- by an exaggerated immune response or hyper-
trates rich in neutrophils, and in the absence of sensitivity to the fungus Aspergillus.
clinical heart failure. Alveolar phase: time in fetal lung development be-
Acute respiratory distress syndrome (ARDS): acute ginning about gestational week 36 and continu-
heterogeneous disease that causes an over- ing up to the second year of life; a time of rapid
whelming pulmonary inflammation that leads alveolar proliferation.
to severe hypoxemia and respiratory failure. Amnioinfusion: procedure in which normal
Adenoid hypertrophy: enlargement of adenoid saline or lactated Ringer’s solution is
tissue. placed into the uterus after rupture of the
Adrenergic: type of medication that produces bron- amniotic sac.
chodilation by stimulating beta-2 receptors on Analgesia: absence of a normal sense of pain.
airway smooth muscles, thus relaxing the muscle Angioedema: allergic reaction that causes rapid
and reversing the airflow obstruction. swelling just below the skin, typically found
Advance directive: instructions that spell out around the lips and eyes.
specific interventions that a patient does or Angioplasty: dilation and widening of a narrowed
does not want to happen; sometimes called a blood vessel.
living will. Anticholinergics: pharmacological agents that
Adverse drug event: injury resulting from medical act by blocking parasympathetic nerve fibers
intervention related to a drug. It can be attribut- such as those seen in airway smooth muscle,
able to preventable and nonpreventable causes. thereby allowing relaxation of the muscle and
Air-oxygen blender: device that brings compressed reduction of the intrinsic vagal tone of the
air and oxygen from a high-pressure source into airway.
a chamber and then sends the gases to a meter- Anti-immunoglobulin E (IgE) therapy: pharmaco-
ing device that controls the mixing of the two logical form of immunotherapy used to prevent
gases. asthma symptoms.
Airway edema: swelling caused by fluid that accu- Antileukotrienes: pharmacological agents that act
mulates in the interstitial spaces of the airway, by preventing leukotrienes from causing airway
limiting localized air flow. inflammation in asthma.
545
2831_Glossary_545-562 13/03/14 3:42 PM Page 546
546 Glossary
Antipyretics: pharmacological agents that reduce Asymptomatic cyanosis: neonate who is blue, with
fever. saturations in the 75% to 85% range without
Aortic stenosis: any discrete narrowing that occurs respiratory distress.
between the left ventricle and the aorta. Atelectasis: collapsed or airless condition of the
Apgar score: measurement used to describe the lung caused by decreased lung compliance,
state of the newborn at various stages after birth inadequate tidal volume, or airway obstruction.
to help guide early post-resuscitative care. Used Atelectrauma: injury to the lung as a result of
by clinicians to assess the quality of their resusci- repeated collapse and re-expansion of alveoli.
tative efforts; evaluates appearance (color), Atopy: genetic predisposition for hypersensitivity
pulse, grimace, activity, and respirations. to allergens.
Apnea of prematurity (AOP): sudden cessation of Atresia: congenital absence or closure of a normal
breathing that lasts for at least 20 seconds or is body opening or tubular structure.
accompanied by bradycardia or oxygen desatu- Atrial septal defect (ASD): opening in the intra-
ration (cyanosis) in an infant younger than atrial septum that creates an anatomical connec-
37 weeks’ gestation (wG). tion between the two uppermost chambers of
Apoptosis: programmed cell death. the heart.
Applicability: usefulness in clinical practice. Atrial septostomy: creates a hole in the atrial wall,
Areflexia: absence of reflexes. causing a wide-open atrial level shunt so that
Arterial switch operation: a surgical procedure used mixing can occur and saturations will stabilize;
to repair transposition of the great arteries; the also known as a Rashkind procedure.
aorta is removed from the right ventricle and Auto-positive end expiratory pressure (PEEP): the
connected to the proximal pulmonary artery to gas trapped in the alveoli at the end of expira-
form a neo-aorta, and the pulmonary artery is tion, caused by inadequate time for exhalation.
removed from the left ventricle and connected to Autogenic drainage: independent breathing tech-
the proximal aorta to form the neo-pulmonary nique in which patients breathe at various lung
artery. volumes to mobilize secretions.
Aryepiglottic folds: prominent folds of mucous Autonomy: represents a person’s right to make
membranes stretching between the lateral decisions that are based on his or her personal
margin of the epiglottis and the arytenoid values, without undue influence from others,
cartilage. including family members or clinicians.
Ascites: fluid in the peritoneal cavity.
Aspiration: material (volatile, solids, or oral secre- B
tions) passing the vocal cords and into the Bacterial tracheitis: infection of the trachea caus-
tracheobronchial tree. ing marked subglottic edema and thick mucus or
Assent: agreement by a child who cannot legally pus-containing secretions; also known as bacter-
give informed consent, but whom parents and ial laryngotracheobronchitis, pseudomembra-
providers believe to have some capacity for nous croup, or bacterial croup.
understanding the decision at hand and for Ball-valve obstruction: blockage of the airway that
expressing preferences. opens during inspiration, allowing air to enter
Assist-control ventilation: form of patient-triggered the alveoli, but closes the airway during exhala-
ventilation that assumes the majority of the tion, causing localized air trapping.
work of breathing, requiring minimal patient Beneficence: obligates clinicians to provide care
effort. The patient is only required to make that will be beneficial to the well-being of the
an initial inspiratory effort and then will be patient and will serve the best interests of the pa-
provided with a full mechanical breath; if no tient. Care provided in this context may include
spontaneous effort is made, a time-triggered cure of disease, relief from pain, or enhancement
mechanical breath will be given. of health and quality of life.
Asthma: common chronic disorder of the airways Best-interest standard: decisions should ideally
with a complex interaction of airflow obstruc- maximize the child’s welfare.
tion, bronchial hyperresponsiveness, and an Bicuspid: a heart valve consisting of two functional
underlying inflammation. leaflets.
Asthma action plan: Written patient disease- Bidirectional Glenn (BDG) procedure: surgical in-
management tool that includes daily management tervention that changes pulmonary blood flow
strategies for asthma and guidelines on how to to a passive flow or drainage system, connecting
recognize and handle worsening symptoms. the superior vena cava to the pulmonary artery,
Asthma severity: intrinsic intensity of disease. bypassing the right heart.
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Glossary 547
Bi-level positive airway pressure (BiPAP): method C
of respiratory support delivered via mask or Caffeine citrate: a type of methylxanthine used as
nasal prongs that provides preset expiratory and a stimulant in the treatment of apnea of prema-
inspiratory pressures, and allows for a preset turity for its very wide therapeutic index.
respiratory rate. Canalicular phase: lung growth occurring during
Bioethics: discipline dedicated to the ethical and gestation weeks 17 to 26; bronchioles continue
moral complexities that arise during the course to multiply, lung vascularization begins, and
of biomedical research and clinical patient care. acinar units begin to form.
Biomarkers: biochemical, genetic, or molecular in- Capillary blood gas (CBG): arterialized blood sam-
dicators that can be used to screen for diseases. ple drawn from a warmed heel or the sides of the
Biventricular hypertrophy: enlargement of both tips of the fingers or toes.
ventricles. Capnometry: measurement of the concentration of
Blalock-Taussig (BT) shunt: surgical procedure carbon dioxide in exhaled gas.
wherein the right subclavian vein is connected Carboxyhemoglobin: attachment of carbon monox-
to the right pulmonary artery to provide pul- ide to a hemoglobin, rendering a red blood cell
monary blood flow. useless for oxygen transport; occurs because
Botulism: progressive neuroparalytic disease that carbon monoxide’s affinity for hemoglobin is
has several distinct clinical presentations; results 200 times that of oxygen.
in acute symmetric descending flaccid paralysis. Cardiac murmur: abnormal heart sound resulting
Breath-actuated nebulizer: inhaled medication de- from turbulent blood flow across a cardiac
livery device that only delivers medication structure.
during inspiration. Cardiomegaly: a heart silhouette occupying greater
Breath-enhanced nebulizer: increases medication than 60% of the thoracic diameter on chest
output when it senses an increase in inspiratory radiography.
flow, then decreases medication delivery when Catastrophic deterioration: sudden change in the
inspiration concludes. status of the infant, which can include hypoten-
Bronchiolitis: viral airway infection that causes in- sion, shocky appearance, need for increased ven-
flammation of the small bronchiolar airways. tilatory support, seizures, acidosis, or anemia.
Bronchoalveolar lavage (BAL): diagnostic tech- Central apnea: absence of breathing that occurs
nique used to determine the pathogenic agent in when the respiratory center of the brainstem
lung infections, particularly those due to oppor- does not send normal periodic signals to the
tunistic pathogens in an immunocompromised muscles of respiration.
patient. Using sterile technique, a BAL catheter Central chemoreceptors: found in the brainstem,
is placed down the endotracheal tube, guided by they send signals to increase ventilation in re-
fiber-optic bronchoscopy. Saline is injected and sponse to low cerebrospinal fluid (CSF) pH,
then aspirated into a specimen trap using suc- which is affected by the amount of CO2 crossing
tion, without withdrawing the catheter. The the blood–brain barrier.
process of injecting and aspirating saline is re- Cerebral perfusion pressure (CPP): equal to the
peated until an adequate sample is obtained or difference between the mean arterial pressure
the patient shows signs of intolerance. (MAP), approximated by multiplying the dias-
Bronchoconstriction: bronchial smooth muscle tolic blood pressure by two-thirds and adding
contraction. that to one-third of the systolic pressure.
Bronchoprovocation: pulmonary function test Cerebrum: largest part of the brain, controlling
that attempts to deliberately stimulate the sensations, voluntary muscular activities, con-
bronchial smooth muscle to assess airway sciousness, and higher mental functions such as
hyperresponsiveness. memory learning, reasoning, judgment, intelli-
Bronchopulmonary dysplasia (BPD): a type of gence, and emotions.
chronic lung disease, currently defined as the CHARGE syndrome: set of congenital defects that
need for supplemental oxygen for at least include coloboma (hole in one of the structures
28 days after birth, assessed at discharge or of the eye), heart abnormalities, atresia choanae,
when the baby is close to his or her estimated retarded mental development, genital hypopla-
full-term age; first described in 1967, but recent sia, and ear deformities.
changes to the pathology and signs and symp- Chemical pneumonitis: inflammation of and dam-
toms have persuaded clinicians to change the age to the lungs caused by the inhalation of
definition to the one described above, and certain chemicals, atelectasis, and pulmonary
change the term to “new BPD.” hypertension.
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548 Glossary
Chest physiotherapy: airway clearance technique Confidentiality: clinician’s duty to not reveal infor-
consisting of percussion, vibration, and postural mation disclosed to them by a patient or about a
drainage. patient.
Chest wiggle factor: continuous, visible vibration of Congenital diaphragmatic hernia (CDH): a serious
the thorax from the umbilicus to the nipple line; congenital malformation that occurs when the
used by clinicians to evaluate adequacy of am- segments of the diaphragm fail to fuse by the
plitude during HFOV. Vibrations are seen from eighth week of gestation, and the abdominal
the groin to the nipple line in prepubescent pa- contents herniate, or protrude through the wall,
tients and from the mid-thighs to the nipple line into the thoracic cavity.
in adults. Congenital vascular malformations: abnormal de-
Choanal atresia: congenital condition in which velopment of arterial, venous, or lymphatic
the posterior portion of the nasal passage ends structures within the airway; their development
in a blind pouch, with complete obstruction can cause airway obstruction that necessitate
of the passageway between the nose and the surgical intervention.
nasopharynx. Conscientious refusal: clinicians’ moral and legal
Choanal stenosis: occurs when the posterior por- right to not provide care that they find ethically
tion of the nasal passages are narrowed but not objectionable.
completely obstructed. Consolidation: solidified alveoli causing decreased
Chorioamnionitis: infection of the amniotic fluid. amounts of oxygen to reach the alveolar capil-
Chorionic villi: vascular projections that include the lary membrane.
fetal portion of the placenta; responsible for the Consumerism: when the physician or medical
exchange of nutrients and waste. provider simply performs whatever action the
Chronic lung disease (CLD): any pulmonary disease parent or family requests.
that results from a neonatal respiratory disor- Continuous positive airway pressure (CPAP):
der; bronchopulmonary dysplasia (BPD) is the method of noninvasive respiratory support pro-
most commonly described form of CLD. vided by mask or nasal prongs that delivers a
Cleft lip: failure of parts of the lip to completely constant positive airway pressure maintained
fuse together during the first 12 weeks of throughout the respiratory cycle.
gestation. Coronary sinus: where cardiac veins return blood
Cleft palate: failure of parts of the hard palate to flow to the right atrium.
completely fuse together during the first 12 weeks Corticosteroids: group of hormones secreted
of gestation, leaving a connection between the by the adrenal cortex in the brain. Can also
oral and nasal cavities. be manufactured synthetically, which acutely
Clinical ethics: application of bioethical principles improves lung mechanics and gas exchange
to patient care, research, and health policy. and reduce inflammatory cells and their
Coarctation of the aorta: discrete narrowing of the products.
descending thoracic aorta, usually distal to the Cranial vault: portion of the skull where the brain
takeoff of the left subclavian artery. is encased.
Columella: anterior, external aspect of the septum. Cricoid pressure: pushing the cricoid cartilage against
Compassion fatigue: results from ongoing stress in the cervical spine, compressing the esophagus to
health-care providers who do not have adequate prevent passive regurgitation; also known as the
ability or time to engage in self-care practices. Sellick maneuver.
Symptoms of compassion fatigue can include Cricothyroidotomy: an emergency surgical airway
apathy, anger, anxiety, self-doubt, difficulty procedure involving an incision between the
focusing, work absences, and substance abuse. cricoid and thyroid cartilages in the midline of the
Complete vascular ring: the abnormal growth and anterior neck; also known as a cricothyrotomy.
continuation of multiple aortic arches that are Critical opening pressure: pressure at which the
present in fetal development. They include dou- lungs begin to expand or inflate.
ble aortic arch and right aortic arch with aber- Cromones: pharmacological agents that act to sta-
rant left subclavian artery, which encircle and bilize mast cells and interfere with chloride chan-
cause compression of both the esophagus and nel function, preventing the release of mediators
trachea. and minimizing airway inflammation.
Concurrent care: simultaneous pursuit of both pal- Croup: a viral-mediated inflammatory condition
liative and curative measures, which benefits of the subglottic airway, which corresponds to
most patients. the area between the true vocal folds and the
Conduit: channel. trachea.
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Glossary 549
Cushing’s triad: a clinical finding in brain injury in Donation after cardiac death (DCD): also called
which bradycardia, hypertension, and irregular non–heart-beating organ donation (NHBOD);
respirations are all present. determined by death within 1 hour of a planned
Cyanotic congenital heart disease: group of neona- withdrawal of life-sustaining therapies, with no
tal heart defects resulting from structural ab- subsequent signs of return of spontaneous circu-
normalities that lead to significant mixing of lation or respiratory effort.
oxygenated and deoxygenated blood and cause Doppler interrogation: using ultrasound to deter-
oxygen saturations less than 85%; should be sus- mine blood flow velocity in different locations in
pected in cases in which a newborn’s oxygen sat- the heart.
uration is low and the baby is cyanotic despite Double aortic arch: one of the more common types
adequate ventilation and oxygenation. of aortic arch abnormality, in which the right
Cyanotic heart defects: congenital abnormalities and left aortic arches are present at birth and en-
that lead to significant mixing of oxygenated circle the trachea and esophagus; the type most
and deoxygenated blood and cause oxygen satu- likely to cause clinical symptoms.
rations less than 85%. Drooling: saliva running from the mouth; a clas-
Cystic fibrosis transmembrane conductance regula- sic sign of epiglottitis that occurs because of
tor (CFTR) gene: mutation in both copies of dysphagia.
this gene is the cause of cystic fibrosis. Dry drowning: laryngospasm that persists after the
Cytochrome oxidase: component of the electron individual loses consciousness so that no fluid
transport chain that turns oxygen into energy enters the lungs.
for the body. Duchenne’s muscular dystrophy (DMD): most com-
mon, lethal, X-linked genetic disease, resulting
D in rapidly worsening muscle weakness and a
Dead space ventilation: area of the lung that is decrease in muscle mass over time.
being ventilated but not perfused. Ductus arteriosus: fetal vessel that connects the pul-
Decannulation: process of removing extracorporeal monary artery to the aorta near the left subclavian
life-support cannulas and ligating the vessels. artery; vents excess blood entering the pulmonary
Deceleration phase: time during labor when the system, bypassing the left side of the heart.
cervix reaches complete dilatation (10 cm) and Ductus venosus: first shunt encountered from the
the presenting part of the fetus (usually the head) placenta in fetal circulation, which connects the
descends into the midpelvis (transition phase). umbilical vein to the inferior vena cava within
Deliberative decision-making: decisions about care the liver.
determined through a discussion with care Dysfunctional swallowing: describes abnormalities
providers and family members. in swallowing or managing oropharyngeal secre-
Demyelination: loss of the myelin sheath on the tions; a well-recognized cause of aspiration in
nerve axon. The myelin sheath is essential in the children.
rapid conduction of nerve impulses through the Dysmotility: abnormality of smooth muscle func-
neuron. tion in gastrointestinal tract.
Diffuse axonal injury: shearing injury to the deeper Dysphagia: painful and difficult swallowing; makes
brain structures. patients unable to manage secretions.
Discontinuing resuscitation efforts: medical decision Dysphonia: hoarseness or difficulty with speech; a
to cease life-saving therapies; can be considered classic sign of epiglottitis due to pain.
when a newborn’s heart rate remains unde- Dyspnea: subjective feeling of shortness of breath.
tectable for 10 minutes during a resuscitation.
Disruption (in fetal development): during fetal de- E
velopment, an abnormally produced defect after Early decelerations: benign changes in fetal heart
normal structural development. rate that represent head compression or changes
Disseminated intravascular coagulation (DIC): in vagal tone after brief hypoxic episodes; begin
process that consumes the factors that clot with the onset of a contraction, reach the lowest
blood; manifests as oozing or bleeding from any point at the peak of the contraction, and return
mucosal site, or into the skin (petechiae). to baseline as the contraction ends.
Do not attempt resuscitation (DNR) order: a written Ebstein anomaly: malformation of the heart in
document specifying that certain interventions, which there are abnormal leaflets of the tricus-
such as mechanical ventilation, chest compres- pid valve, found between the right atrium and
sions, or defibrillation, will not be attempted if a ventricle, as well as displacement of the leaflets
patient’s condition deteriorates. into the right ventricle.
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550 Glossary
Echocardiogram: non-invasive tool using ultra- is a biomarker that indicates poorly controlled
sound to visualize cardiac structures. asthma.
Electrocardiogram (EKG): reading of the electrical Expressive language: a person’s capacity to commu-
activity of the heart. nicate his or her current thoughts and feelings.
Embryonic phase: phase of human development Extracorporeal life support (ECLS): technique used
from conception to gestation week 6; the phase to support the heart and/or lungs externally
in which the respiratory epithelium begins to when the native heart and/or lungs are no longer
grow, including the lung buds and trachea. able to provide adequate support.
Empyema: pus in the pleural cavity. Extracorporeal membrane oxygenation (ECMO):
Endobronchial masses: unexpected growth within a practice of placing an intensive care unit (ICU)
bronchus; uncommon in children. patient on artificial support, giving the native
Endocarditis: inflammation of the heart valves. lungs and/or heart a period of rest.
Endoderm: innermost germ layer of the embryo. Extracorporeal membrane oxygenation (ECMO)
Endoscopy: diagnostic test in which a camera is heaters: heat blood before reinfusing it into the
used on the end of a flexible tube inserted into patient to preserve thermal regulation.
the body for definitive diagnosis; can be used Extracorporeal membrane oxygenation (ECMO)
to augment successful intubation and airway pump: operates as a servo-controlled, positive
protection. displacement pump. Has two rollers that will
Epiglottitis: bacterial infection of the epiglottis and optimally occlude or squeeze the tubing in the
the surrounding tissues, including the entire pump and direct blood through the tubing, cre-
supraglottis (the portion of the larynx above the ating pressure and flow through the system.
vocal cords), which can progress rapidly to life- Exudative stage: first stage of acute respiratory dis-
threatening airway obstruction. tress syndrome; begins when the inflammatory
Epinephrine: in respiratory therapy, an inhaled cascade is triggered from a direct or indirect
pharmacological agent given to reduce upper lung injury, resulting in damage to the cellular
airway inflammation; usually given as racemic lung structure. Outpourings of inflammatory
epinephrine. mediators increase the permeability of the alveo-
Epithelialization: healing by the growth of epithe- lar capillary membrane.
lium over an open wound surface. Exudative tracheitis: bacterial infection of the
Escharotomies: incisions in the skin that can release trachea causing edema and oozing of fluid and
the pressure from the eschars and changes in cellular debris from the airway walls.
surrounding tissues.
Eschars: areas of dead tissue that occur after severe F
burns. Fetal bradycardia: fetal heart rate (FHR) less than
Esophageal atresia (EA): congenital defect in 110 beats per minute.
which the esophagus ends in a blind-ended Fetal circulation: the circulatory pathway for blood
pouch rather than connecting normally to in a fetus; includes a system of shunts and differ-
the stomach. ences in normal blood pressures that diverts
Euthanasia: purposeful administration of medica- blood flow through alternative tracts compared
tions to end life; illegal in the United States. with adult circulation.
Evidence-based medicine: conscientious, explicit, Fetal heart rate (FHR) monitoring: continuous elec-
and judicious use of current best evidence in tronic monitoring used for intrapartum fetal
making decisions about the care of the individ- surveillance.
ual patient. Fetal lung fluid: fetal fluid that is secreted by epithe-
Exacerbations: increase in symptoms. lial cells of the lung to help maintain the patency
Excision: resection; removal of a portion or all of a of the airways and acinar units during their
structure. growth until delivery; chemically has a very low
Exclusivity: patent protection that allows manufac- pH, bicarbonate, and protein levels, but higher
turing a drug without competition from other sodium and chloride concentrations than amni-
suppliers for a period of time. otic fluid.
Exercise-induced asthma: symptoms present only Fetal scalp blood sampling: used during labor when
during physical exertion. the fetal heart rate monitoring is nonreassuring
Exhaled breath condensate: biomarker test for to determine the acid-base status of the fetus;
asthma. Exhaled air condenses when it comes obtained from the scalp after the membranes
into contact with a cooled collector, allowing the have been ruptured.
collection of respiratory particles, droplets, and Fetal tachycardia: fetal heart rate (FHR) greater
water vapor; low exhaled breath condensate pH than 160 beats per minute.
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Glossary 551
Fibrotic stage: third stage of acute respiratory dis- Gestation: time frame from conception to birth.
tress syndrome; results in total lung remodeling, Glasgow coma scale (GCS): clinical tool often used
leading to widespread fibrosis and scarring. to quickly assess consciousness and neurological
Fixed split S2: heart murmur heard in a patient status during the acute assessment of a patient
with an atrial septal defect who has more blood who has suffered intracranial injury.
flow traveling across the pulmonary valve, thus Glossoptosis: obstruction of the airway by the bulk
causing the pulmonary valve to close after the of the tongue.
aortic valve in inspiration and exhalation. Glottic web: membrane spread between the vocal
Flaccid paralysis: relaxed or absent muscular tone. folds near the anterior commissure.
Flow inflating bag: type of manual resuscitation Glottis: sound-producing apparatus of the larynx,
bag/bag valve mask; will fill with oxygen only including the two vocal folds and the intervening
when a compressed source of oxygen is attached space; opens to allow inspiration and closes
and requires a tight seal between the mask and to facilitate speech, airway protection, and
the patient to remain inflated. increases in intrathoracic pressure.
Fomites: airway secretions that live on inanimate Goals of care: the determination by family and
objects. clinician of desirable and undesirable patient
Fontan procedure: third stage of surgical treatment outcomes.
of hypoplastic left heart syndrome; routes infe- Golden minute: the 60 seconds that neonatal resus-
rior vena cava flow from the right atrium to the citation program (NRP) providers have to com-
pulmonary artery via an intracardiac or extrac- plete the initial assessment and interventions of
ardiac conduit. resuscitation.
Foramen ovale: fetal shunt that provides an open- Grunting: noise produced by breathing against a
ing between the right and left atria. partially closed glottis; a form of expiratory
Forced expiratory technique (FET): creates an in- retard when neonates partially close their
creased expiratory airflow and thereby mobilizes glottis at the end of expiration to create a back
the mucus from the distal, small airways into pressure in the lungs with the goal of stabilizing
the more central airways where it can then be alveoli and terminal airways to prevent col-
expelled with a cough; also known as a huff. lapse; signifies significant respiratory distress
Foreign antigen: substances from outside the body in an infant.
capable of eliciting an immune response. Guillain-Barré syndrome: neurological condition
Fractional exhaled nitric oxide (FeNO): most that affects peripheral nerves and presents as
widely used exhaled biomarker of airway inflam- progressive ascending weakness in both arms
mation in asthma; measures the amount of nitric and legs and areflexia.
oxide in exhaled breath. Gyri: numerous folds covering the two cerebrum
Functional residual capacity (FRC): volume of gas hemispheres; along with sulci, serves to increase
remaining in the lungs after a normal resting the surface area of the brain; begins to appear
expiration. around 14 weeks of gestation.
Futility: concept that describes medical treatments
that are not expected to result in any benefit to H
the patient. Hamartomas: congenital masses that may occur in
the posterior of the nose, near the internal open-
G ing of the eustachian tube orifice.
Gangliosides: complex molecules that are in nerve Heated, humidified, high-flow nasal cannula
cell membranes and are instrumental in recogni- (HFNC): an oxygen delivery device that pro-
tion of cells and cell-to-cell communication. duces a high flow of gas at nearly 100% humid-
Gastroschisis: abdominal wall defect characterized ity gas, virtually free of droplets, at body
by protrusion of the intestines through the temperature or above; this allows higher gas
abdominal wall not covered by amnion. flows to be tolerated by patients.
Gentle ventilation: lung-protective strategy in which Heliox: gas mixture of helium and oxygen used to
a peak inspiratory pressure is selected that pro- treat hypoxemia during airway obstruction; is re-
vides adequate air entry and an respiratory rate ported to be effective in a variety of respiratory
of 20 to 40 breaths/min is initiated and adjusted conditions such as upper airway obstruction,
to maintain a PaCO2 of 40 to 60 mm Hg. status asthmaticus, decompression sickness,
Germinal matrix: a weakly supported and highly postextubation stridor, bronchiolitis, and acute
vascularized area of the lateral ventricles in the respiratory distress syndrome.
developing brain; formed to assist in rapid cellu- Hemoptysis: expectoration of blood arising from
lar formation. the airway or lungs.
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552 Glossary
Herniate: to protrude abnormally from an enclosed Hyperoxia test: arterial blood gases are obtained
cavity. from the right radial artery on room air and
Heated, humidified, high-flow nasal cannula 1.0 fractional concentration of inspired oxygen
(HFNC): an oxygen delivery device produces a (FIO2) and compared to assess a patient’s ability
high flow of highly humidified air, virtually free to oxygenate; cyanotic heart defects should be
of droplets, at body temperature or above. The suspected when partial pressure of oxygen
high humidity allows for much higher flow rates (PaO2) is lower than 150 mm Hg on FIO2 1.0;
to be tolerated by neonatal patients without the pulmonary disease should be suspected if PaO2
risk of nasal mucosal drying or bleeding. is greater than 150 mm Hg on FIO2 1.0.
High-frequency chest wall oscillation (HFCWO): Hypertrophy: increase in size of a vessel or anatom-
technique to clear mucus using an inflatable ical structure.
jacket with an air pulse generator that rapidly Hypoplasia: increased distance between alveolar
fills and deflates the jacket at a set pressure. spaces and capillaries, which worsens gas ex-
High-frequency jet ventilation (HFJV): a method of change and lung tissue underdevelopment.
mechanical ventilation that uses a transitional Hypoplasia: organ or tissue underdevelopment.
flow pattern of gas delivery that allows fresh, Hypoplastic: undeveloped veins.
oxygen-rich gas to travel down the center of the Hypoplastic left heart syndrome (HLHS): cyanotic
airways at very high velocity in small bursts, get- heart disease in which parts of the left side of the
ting downstream of restricted portions of the heart do not fully develop.
airways reaching the alveoli and bypassing dam- Hypoxic-ischemic encephalopathy: acute or suba-
aged portions of the lung without leaking. cute brain injury due to hypoxia and acidosis.
High-frequency oscillatory ventilation (HFOV):
piston-diaphragm oscillator that uses rates of I
180 to 900 coupled with a directly set mean Iatrogenic: lung injury caused by medical interven-
airway pressure to manage oxygenation and tions, such as mechanical ventilation.
ventilation. Immunocompromised: a state in which the immune
High-frequency ventilation (HFV): uses rapid res- system’s ability to fight infectious disease is defi-
piratory rates (>150 breaths/min) and very cient or entirely absent.
small tidal volume (usually less than anatomic Immunotherapy: therapy involving subcutaneous
dead space) to provide ventilation and lung injections of increasing amounts of a known
protection. allergen.
Histamine: chemical mediator producing an imme- Incubator: used in the neonatal population to con-
diate allergic response. trol environmental temperature and humidity;
Hospice agencies: focus specifically on providing helps minimize heat loss via conduction and
care at home for dying patients. promotes a quiet, dark environment, reducing
Hospital ethics committee: multidisciplinary com- external stimuli that can be distressing to prema-
mittee composed of members from both the ture infants.
medical and lay communities. Induced hypothermia: deliberate lowering of body
Hyaline membrane disease (HMD): lung disease of temperature with the goal of minimizing brain
premature infants first characterized in the early injury after severe and prolonged hypoxia; cool-
20th century because of the unique cellular char- ing is initiated within 6 hours of birth; the infant
acteristics of the lung; more commonly called is cooled for 72 hours and then gradually
respiratory distress syndrome (RDS). warmed.
Hydrocarbons: chemical compounds made only of Informed consent: process that requires clear com-
hydrogen and carbon. munication to family members about risks and
Hydroxycobalamin: precursor to vitamin B12, benefits, adequate time for questioning and un-
which binds cyanide, forms cyanocobalamin, derstanding, protection from undue influences,
and is excreted without any toxic effects. and transparency about the right to revoke con-
Hygiene hypothesis: the theory that, in early life, sent at any point.
nature may “immunize” against the allergic Inhaled antibiotics: nebulized form of pharmaco-
march through microbial exposures of the respi- logical antibacterial agents, frequently used
ratory tract, gastrointestinal tract, and possibly for patients with cystic fibrosis who have re-
the skin. current airway infections; the rationale for the
Hyperbaric chambers: pressure chambers that allow inhaled route is that it delivers a high concen-
the delivery of fractional concentration of tration of drug to the airway surface, where it
inspired oxygen (FIO2) of 1.0 at higher than is most needed, while minimizing systemic
atmospheric pressure. drug toxicity.
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Glossary 553
Inotropes: pharmacological agents used to improve Late decelerations: indicative of uteroplacental
cardiac contractility. insufficiency and, if recurrent, considered to rep-
Insufflation-exsufflation device: mucus-clearing resent fetal compromise and need further evalu-
device that helps with airway clearance and pre- ation for delivery; the temporal relationship is
vents accumulation of mucus in the lungs and variable to the onset of the contraction, occur-
airways of patients with a weak cough; works by ring after the peak of the contraction, persisting
inflating the lungs with a positive pressure, fol- after the contraction stops, and gradually re-
lowed by an active negative pressure exsufflation turning to baseline.
that creates a peak and sustained flow high Latent phase: first phase of labor, characterized by
enough to provide adequate shear and velocity a time when contractions become more coordi-
to loosen and move secretions toward the mouth nated and the cervix reaches 4 cm dilatation.
for suctioning or expectoration. Law of Laplace: states that volume will be prefer-
Intracranial pressure (ICP): pressure within the entially delivered into segments of the lung that
portion of the skull where the brain is encased. are partially open.
Intrapulmonary percussive drainage: mucus- Leukocytosis: increase in the number of white
clearing device using a mask or mouthpiece that blood cells.
delivers small bursts of positive pressure (5 to Leukotrienes: potent bronchoconstrictors derived
35 cm H2O) at rates of 100 to 300 cycles/min, mainly from mast cells mediate the inflamma-
superimposed on a patient’s own breathing; can tory response; inhibition of this mediator has
be effective in treating atelectasis. been shown to improve lung function and
Intrapulmonary shunt: lung perfusion without reduce asthma symptoms.
ventilation. Ligation: surgical tying to correct a malfunction, as
Intraventricular hemorrhage (IVH): neonatal com- provided in correcting a patent ductus arteriosus
plication that occurs most commonly in prema- in neonatal life.
ture infants, characterized by bleeding within the Limb-girdle muscular dystrophy (LGMD): describes
ventricles of the brain. a diverse group of muscular dystrophies that are
caused by specific protein defects in muscle.
J Lipoids: oils and animal fats; may result in an un-
Justice: principle that requires health care to be common cause of respiratory distress in children.
delivered fairly so that no one patient group Long-acting beta agonists (LABAs): pharmacologi-
unduly suffers the burden of scarce resources. cal agents used for long-term control and pre-
Justice means that all individuals have a right vention of symptoms in moderate or severe
to equal access to medical care, and that indi- persistent asthma.
viduals have a right to a minimum standard of Lung transplantation: surgical technique that re-
health care. places a damaged lung with a healthy, donor
lung or lobe.
K
Ketamine: anesthetic agent with strong analgesic M
action that mediates bronchodilation. Macroglossia: an enlarged tongue.
Magnesium: an ion found in abundance in the
L human body; when given intravenously, has been
Labor: passage of the fetus and the placenta from shown to have beneficial effects on smooth mus-
the uterus to the extrauterine world (childbirth). cle relaxation and inflammation in the airway.
Laryngoceles: abnormal outpouchings of the laryn- Maladaptation: pulmonary vascular bed is nor-
geal mucosa in the laryngeal ventricles. mally developed; however, adverse perinatal
Laryngomalacia: softening of the tissues of the conditions cause active vasoconstriction and in-
larynx; the most common laryngeal anomaly terfere with the normal postnatal reduction in
and congenital cause of stridor. pulmonary vascular resistance, causing persist-
Laryngopharyngeal reflux (LPR): reflux of gastric ent pulmonary hypertension of the newborn
acid into the pharynx and larynx. (PPHN).
Laryngospasm: an involuntary muscle contraction Maldevelopment: situation in which the lungs de-
of the laryngeal cords; helps to prevent fluid or velop normally, but the pulmonary arteriole
other materials from entering the lungs. muscle layer is abnormally thick and grows in
Laryngotracheobronchitis (croup): a viral disease smaller vessels that normally have no muscle
causing airway narrowing involving the subglot- cells, causing pulmonary hypertension.
tis, presenting with a “barky” cough, stridor, Malformation: abnormal or anomalous formation
and occasionally hoarseness. or structure; deformity.
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554 Glossary
Mandatory vaccination: some health-care systems Methacholine: parasympathomimetic broncho-
require personnel to be vaccinated against cer- constrictor that acts directly on smooth muscle
tain diseases, such as influenza. receptors and will cause immediate bronchocon-
Mast cells: concentrated beneath the mucous mem- striction; the inhalant of choice when perform-
branes of the respiratory tract; when covered ing bronchoprovocation testing.
with IgE molecules, they will bind with foreign Methemoglobin (MetHb): red blood cell that loses
antigens and stimulate degranulation, releasing an electron from the ferrous ion and is no longer
such mediators as histamine, prostaglandin D2, capable of binding with oxygen.
and leukotrienes. These mediators produce an Methylxanthines: stimulant medications, generally
immediate hypersensitivity reaction within the stimulating the central nervous system and
airway walls. Mast cells may also be activated cardiac muscles; have also been known to stimu-
by osmotic stimuli, such as during exercise- late the respiratory drive, increase diaphragm
induced bronchospasm, and they may poten- activity, increase minute ventilation, enhance
tially continue to send signals stimulating in- chemoreceptor sensitivity to CO2, reduce peri-
flammation even when exposure to allergens is odic breathing, reduce hypoxic respiratory de-
limited. pression, increase metabolic rate, increase
Maximum expiratory pressure (MEP): The pres- oxygen consumption, and stimulate diuresis.
sure obtained when a patient breathes out Micrognathia: abnormal smallness of the lower
quickly and forcefully to residual volume. jawbone.
Maximum inspiratory pressure (MIP): the pressure Mixed apnea: dysfunctional breathing that com-
obtained when a patient quickly breathes in fully bines elements of obstructive and central sleep
to total lung capacity. apneas.
Mean airway pressure (Paw): close reflection of Monro-Kellie doctrine: the total volume within the
mean alveolar pressure calculated on all me- cranial vault is strictly limited by the fixed walls
chanical ventilators; used to evaluate the of the skull.
amount of support provided to mechanically Moral distress: dilemma a clinician experiences
ventilated patients. when he or she is prevented from doing what the
Meconium: newborns’ first stool, which is the by- clinician feels is best for the patient, or when cli-
product or metabolic waste of gestation. nician feels obligated to do something not in the
Meconium aspiration syndrome (MAS): respiratory patient’s best interest.
distress occurring soon after delivery in a meco- Morbidity: number of deceased patients.
nium-stained infant, which is not otherwise Mucolytics: pharmacological therapies designed to
explainable and is associated with a typical radi- thin airway secretions.
ographic appearance of patchy infiltrates or Mucus: viscous fluid normally made up of a combi-
irregular streaky, linear densities and consolida- nation of mucin, leukocytes, inorganic salts,
tion throughout the lung fields. water, and epithelial cells.
Meconium aspirator: device that allows for attach- Muscle relaxant: pharmacological therapy used to
ment of wall suction and use of the ETT as a eliminate patient spontaneous movement.
large-bore suction device within the trachea at Myasthenia gravis (MG): autoimmune disorder
delivery in a nonvigorous newborn with meco- characterized by fluctuating muscle weakness
nium-stained amniotic fluid. and fatigue.
Meconium ileus: failure to pass meconium after Myelomeningocele: birth defect in which the back-
birth, causing impaction of meconium in the bone and spinal canal do not close before birth;
large intestines. a type of spina bifida.
Medical error: implies a preventable adverse event, Myocardial cells: cardiac muscle cells.
a threat to patient safety that could have been Myocardial ischemia: inadequate supply of blood
avoided. and oxygen for the demands of the heart
Medication error: any preventable event that muscle.
occurs in the process of ordering or delivering
a medication, regardless of whether an injury N
occurred or the potential for injury was Nasal endoscopy: procedure using a narrow fiber-
present. optic or rigid telescope or otoscope to evaluate
Mesenchyme: embryonic connective tissue. upper airway abnormalities.
Mesentery: the double-layer peritoneal fold Natural history of asthma: refers to its course over
attaching the small intestine to the posterior an individual’s lifetime; its progression and symp-
body wall. toms can vary throughout an individual’s life.
Mesoderm: middle germ layer of the embryo. Necrosis: death of cells, tissues, or organs.
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Glossary 555
Necrotizing enterocolitis (NEC): serious compli- Noninvasive positive-pressure ventilation (NIPPV):
cation of prematurity that primarily affects method of respiratory support delivered via
the gastrointestinal (GI) tract; the process mask or nasal prongs that provides preset expi-
of development includes hypoxic-ischemic ratory and inspiratory pressures and allows for a
and inflammatory damage that can result in preset respiratory rate.
death of the tissues in almost any region of Nonmaleficence: obligates clinicians to care for
the GI tract. patients in a way that causes no harm.
Needle decompression: emergency procedure in Nonvigorous: having a depressed respiratory effort,
which a needle is inserted into the pleural cavity poor muscle tone, and/or heart rate less than
to relieve air pressure in the thoracic space, 100 beats per minute.
during a tension pneumothorax. Normothermia: normal body temperature.
Negative pressure pulmonary edema: occurs when a Norwood procedure: first stage of surgical treat-
person attempts to take deep breaths against a ment for hypoplastic left heart syndrome, which
closed glottis, usually during submersion in consists of four steps: creation of a neo-aorta
water; the negative pressure generated can be using the pulmonary artery and homograft ma-
very high and can damage the alveolar and cap- terial to reconstruct the aortic arch in continu-
illary bed, leading to fluid being pulled into the ity with the right ventricle; removal of the atrial
lung parenchyma as with a vacuum. septum; providing a source of pulmonary blood
Neonatal Resuscitation Program (NRP): an edu- flow via a systemic-to-pulmonary artery shunt
cational program jointly sponsored by the (such as a Blalock-Taussig shunt or Sano modi-
American Academy of Pediatrics and the fication); and ligation of the patent ductus
American Heart Association (AHA); designed arteriosus.
to teach an evidence-based approach to resus-
citation of the newborn to hospital staff, in- O
cluding physicians, nurses, and respiratory Obstructive apnea: absent or dysfunctional breath-
therapists, who care for newborns at the time ing that occurs when the upper airway is inter-
of delivery. mittently blocked.
Neurogenic pulmonary edema (NPE): sudden in- Off-label use: term used when a medication is pre-
crease in pulmonary interstitial fluid associated scribed and delivered for an intended use other
with numerous central nervous system insults. than that in the proposed labeling.
Neuropathy: disease or malfunction of the nerves. Omphalocele: a midline defect of the abdomen
Newborn screening: blood test that identifies infants with the umbilical cord rising from the middle,
who may have cystic fibrosis (CF); not all in- encapsulated by the peritoneal sac; the small
fants with a positive newborn screen actually intestines, liver, and stomach are frequently the
have CF. Infants with a positive newborn herniated organs.
screening test must have additional testing be- Optimal positive end expiratory pressure (PEEP):
fore a definitive diagnosis of CF can be made. pressure at which static lung compliance is maxi-
Nitric oxide (NO): substance produced by nearly mized and oxygen transport is greatest.
every cell and organ in the human body. NO Ostium primum ASD: defect in the septum primum
performs many functions including vasodilation, that occurs directly superior to the atrioventricu-
platelet inhibition, immune regulation, enzyme lar valves.
regulation, and neurotransmission. Ostium secundum ASD: occurs when the septum
Nitrogen washout: caused by delivery of 1.0 frac- primum does not grow to completely cover and
tional concentration of inspired oxygen (FIO2), fuse with the septum secundum.
with the potential of causing absorption atelec- Ostomies: surgically formed openings allowing a
tasis. Nitrogen acts as an alveolar-stabilizing portion of the intestines to pass through a fistula
gas, preventing alveolar collapse or atelectasis to the skin surface.
during gas exchange. When FIO2 is increased, Oxygen hood (oxyhood): clear plastic enclosure that
the amount of nitrogen within the alveoli de- is placed around a neonate’s head and connected
creases (is “washed out of the alveoli”), and it is to a humidified gas source to provide a fixed
no longer available for alveolar stabilization. oxygen concentration.
Non–heart-beating organ donation (NHBOD): a Oxygenation index (OI): equation that assesses
process for organ procurement where organs are the severity of lung dysfunction that is used fre-
harvested if the patient progresses to death quently to help determine the need for escalating
within one hour of withdrawal of life-sustaining respiratory care.
therapy, and death is maintained for an estab- Oxygenator: device for mechanically oxygenating
lished number of minutes. the blood.
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556 Glossary
Glossary 557
Pneumomediastinum: condition in which extra- Professional ethics: address the interactions among
alveolar air dissects through the lung intersti- professionals, individuals, and society.
tium and ruptures into the mediastinum. Proliferating: growing
Pneumonia: inflammation of the lung parenchyma, Proliferative stage: second stage of acute respiratory
usually due to infection with bacteria, viruses, or distress syndrome; characterized by the prolifera-
other pathogenic causes. tion (rapid increase) of type II pneumocytes
Pneumopericardium: air within the pericardial sac. and fibroblasts (cells that play a role in wound
Pneumoperitoneum: free air in the abdomen. healing).
Pneumothorax: air in the pleural cavity. Prone positioning: placement of a patient “face-
Poiseuille’s law: used to calculate endotracheal tube down,” which may be considered for a mechani-
resistance, it states that resistance is a function cally ventilated patient if he or she continues to
of the tube length divided by the radius of the have difficulty oxygenating or ventilating.
tube to the fourth power. Prostaglandin E (PGE): hormone-like substances
Polyhydramnios: abnormally high volume of amni- that perform a variety of functions in the body.
otic fluid. Pseudoglandular phase: phase of fetal lung develop-
Polysomnogram: a sleep study. ment occurring during weeks 7 to 17; named so
Pores of Kohn: minute openings thought to exist for the gland-like appearance of the lung during
between adjacent alveoli. this stage; a time of rapid airway proliferation,
Positive end expiratory pressure (PEEP): mechani- larynx and vocal cord development, and com-
cal ventilation setting that maintains a pressure pletion of the oropharynx and nasopharynx.
within the alveoli throughout the respiratory Ptosis: drooping eyelids.
cycle, measured at the end of exhalation. Pulmonary atresia: abnormal development of the
Positive expiratory pressure (PEP): airway clear- pulmonary valve, which sits between the right
ance strategy in which positive pressure is cre- ventricle and the pulmonary artery.
ated in the airways by resisting expiration. Pulmonary edema: leaking of fluid from the capil-
Post-ductal SpO2: oxygen saturation taken from an laries in the lungs into the interstitium and
area of the body whose arterial blood supply is alveolar sac.
after the ductus arteriosus; typically from the Pulmonary exacerbation: characterized by increased
lower limbs. airway secretions, infection, and inflammation.
Postural drainage: chest physiotherapy technique Pulmonary function testing (PFT): one of several
that uses gravity to mobilize mucus from differ- different tests used to evaluate the condition of
ent lung segments. the respiratory system; they are direct measure-
Preductal SpO2: oxygen saturation taken from an ments of airflow and lung volumes.
area of the body whose arterial blood supply Pulmonary hypertensive crisis: characterized by a
comes prior to the ductus arteriosus, including rapid increase in pulmonary vascular resistance,
the head and the right upper limb. which results when the pulmonary artery pres-
Pressure control ventilation: method of mechanical sure exceeds systemic blood pressure and right
ventilation that allows the pressure delivered heart failure ensues.
to the lungs to remain constant, and volume Pulmonary hypoplasia: congenital underdevelop-
delivery will change with lung characteristics; ment of lung tissue during fetal growth.
a volume of gas is delivered to the lungs over a Pulmonary interstitial emphysema (PIE): dissection
specified time period until a clinician-chosen of air into the tissue of the lungs surrounding the
“safe pressure” is reached. pulmonary vasculature.
Pressure support ventilation: an assisted form of Pulmonary vascular resistance (PVR): amount of
ventilation that provides a constant pressure resistance there is to blood flow through the
during ventilation when it senses a patient’s lungs, caused by dilation or constriction of the
inspiratory effort. pulmonary arteries.
Preterm: live birth occurring before 37 week’s Pulmonary vein confluence: location where the pul-
gestation. monary veins come together.
Primary apnea: absence of breathing at birth; Pulmonic stenosis: narrowing in the right ventricu-
stimulation will result in resumption of lar outflow tract between the right ventricle and
breathing. the main pulmonary artery.
Professional competence: professional ethics require Pulse pressure: difference between systolic blood
that clinicians attain professional competency pressure and diastolic blood pressure.
via an appropriate level of training relevant to Pulsus paradoxus: a greater than 15 mm Hg drop in
their area of expertise. systolic blood pressure during inspiration.
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558 Glossary
Glossary 559
Septum secundum: muscular structure that grows Subglottic stenosis: narrowing of the airway below
downward from the upper portion of the embry- the vocal folds.
ological atria. Sulci: furrows separating gyri in the brain.
Serosanguineous: body fluid that consists of blood Supraglottic larynx: portion of the larynx above
and serum. the vocal cords.
Shock: Hypotension with decreased systemic Supraglottis: portion of the larynx just above the
perfusion. glottis, including the epiglottis, bilateral false
Short-acting beta agonist (SABA): pharmacological vocal folds, bilateral arytenoids, and the bilat-
agent that relaxes airway smooth muscles during eral aryepiglottic folds, which serve to protect
bronchoconstriction to reverse the signs and the airway from aspiration.
symptoms of acute airflow obstruction, namely Supravalvar stenosis: narrowing of the vessel above
cough, chest tightness, and wheezing. the heart valve at the suture line of the connec-
Silent aspiration: aspirating without eliciting reflex tion site of the great vessels.
to cough to remove material from the airway. Surfactant: a chemically complex agent whose
Sinus venosus: located directly inferior to the junc- main function is to stabilize the air-liquid inter-
tion of the superior vena cava and the right face of the alveoli and bronchioles and to lower
atrium; almost always associated with partial surface tension.
anomalous pulmonary venous return. Surfactant-replacement therapy: installation of arti-
Sinusoidal FHR pattern: fetal heart rate pattern ficially derived surfactant directly into the lungs.
associated with severe fetal hypoxia, acidosis, Synchronized intermittent mandatory ventilation
or anemia; consisting of regular, smooth oscilla- (SIMV): form of patient-triggered mechanical
tions of the baseline variability; typically lasts ventilation that will deliver a preset number of
for at least 10 minutes. mechanical ventilator breaths, attempting to
Sniffing position: airway positioning so that the pa- synchronize them with patient efforts; any addi-
tient’s head and chin are thrust slightly forward, tional patient effort beyond the preset manda-
with the intent to open the airway tory respiratory rate will be monitored by the
Sodium thiosulfate: pharmacological agent used in ventilator but not supported in any way; if no
cyanide poisonings that can help increase the spontaneous effort is sensed, a time-triggered
conversion of cyanide to specific nitrates. This mechanical breath will be delivered.
prevents the binding with cytochrome oxidase Systemic vascular resistance (SVR): the resistance
so that aerobic metabolism will continue. to blood flow through the peripheral system.
Spinal cord injury (SCI): partial or complete frac-
ture, compression, or stretching of the spinal T
cord. Tamponade: accumulation of fluid or air in the
Spinal muscular atrophy (SMA): characterized by pericardial sac that impairs the filling of the
lower motor neuron degeneration, and respira- heart during diastole and impedes cardiac
tory muscle strength is disproportionately output.
weaker than the diaphragm muscle; a leading Target effect: method of drug delivery in which a
cause of death in children younger than 2 years drug is dosed until the desired effect is achieved
of age. or until unacceptable side effects or toxicity
Spirometry: measurement of airflow and lung occur.
volumes. Team support: services provided to health-care
Starling’s forces: vaginal squeezes of the chest as an team members to assist them in coping with a
infant progresses through the birth canal. patient’s death.
Static compliance: measurement of lung distensibil- Tension pneumothorax: life-threatening accumula-
ity taken under conditions of no airflow. tion of air in the pleural cavity; each breath
Status asthmaticus: severe, persistent, and intractable forces new air through the rupture that does not
asthma that does not respond to initial short- escape through the route of entry.
acting beta-agonist therapy. Terminal extubation: ventilator is discontinued and
Subglottic: the lower part of the larynx just below the endotracheal tube removed without weaning
the vocal cords to the top of the trachea. the ventilator prior to doing so.
Subglottic cysts: a closed sac or pouch that con- Terminal sedation: refers to sedation to uncon-
tains fluid, semifluid, or solid material, found in sciousness at the end of life, when symptoms
the area below the glottis. cannot be managed by other means.
Subglottic hemangiomas: an abnormal buildup of Terminal weaning: method of slowly lowering ven-
blood vessels in the subglottic tissue, which can tilatory support over hours (or days) prior to
cause airway obstruction. removing the endotracheal tube.
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560 Glossary
Tet spell: occurs in patients with tetralogy of Tracheostomy: permanent opening created during
Fallot; a sudden increase in right ventricular a tracheotomy to provide and secure an open
outflow tract obstruction causing a period of airway.
hypercyanosis. Tracheotomy: surgical procedure to create an open-
Tetanus: neurological disease caused by a neuro- ing in the trachea for long-term airway stabiliza-
toxin produced by the anaerobic bacterium tion; incision into the trachea through the skin
Clostridium tetani. and soft tissues of the neck.
Tetralogy of Fallot (TOF): congenital cyanotic Transcutaneous monitoring: method of electro-
heart defect caused by a combination of four chemically measuring skin-surface partial pres-
conditions: ventricular septal defect (VSD); an sure of oxygen (PO2) and partial pressure of
aorta that overrides the VSD; obstruction of the carbon dioxide (PCO2) by heating localized
right ventricular outflow tract; and right ventric- areas of the skin to induce hyperperfusion.
ular hypertrophy. Transient tachypnea of the newborn (TTN): condi-
Time-cycled pressure-limited (TCPL) ventilation: tion of term or near-term infants, characterized
the historically most common form of mechani- by mild respiratory distress during the first few
cal ventilation for neonates, providing positive hours of life. It is caused by failure to clear fetal
pressure ventilation at a regular frequency lung fluid prior to delivery.
without regard to patient respiratory effort; me- Transillumination: placement of a high-intensity
chanical breaths will be delivered to a preset light source on the thorax to diagnose or rule
mandatory pressure and initiated and termi- out a pneumothorax in a neonate.
nated based on preset time. Transposition of the great arteries (TGA): congeni-
Time-triggered breaths: mandatory ventilator tal cyanotic heart defect that occurs when the
breaths. two main arteries leaving the heart have changed
Tissue test: an evaluation method used to identify places so that the aorta arises from the right ven-
choanal atresia, whereby the practitioner holds a tricle and the pulmonary artery arises from the
piece of tissue or wisp of cotton in front of each left ventricle.
nare—if choanal atresia is present, the tissue Traumatic brain injury (TBI): caused by a bump,
(or cotton wisp) will not move with respiration. blow, or jolt to the head or a penetrating head
Tocolytic drugs: pharmacological agents used to injury that disrupts the normal function of the
inhibit or dampen uterine contractions. brain.
Tonsillar hypertrophy: palatine tonsils (commonly Trismus: facial rigidity that often starts with the
referred to as tonsils), situated between the ante- facial muscles related to chewing and smiling;
rior and posterior tonsillar pillars, become commonly described as lockjaw.
enlarged, causing airway obstruction. Truncus arteriosus: congenital cyanotic heart defect
Total anomalous pulmonary venous return in which a single great vessel leaves the heart
(TAPVR): type of congenital cyanotic heart and supplies the systemic and pulmonary
defect that results when there is no connection circulation.
between the pulmonary vein confluence and Type I cells: alveolar cells that form the structure
the left atrium. of the alveolar capillary membrane.
Total obstruction: airway occlusion that will not Type II cells: alveolar cells that make, store, and
allow inhalation or exhalation and leads to secrete things such as type I cells, fetal lung
atelectasis and hypoventilation. fluid, and pulmonary surfactant.
T-piece resuscitator: a mechanical device designed
to deliver manual breaths at a set flow that pro- U
vides consistent peak inspiratory pressure and Underdevelopment: persistent pulmonary hyperten-
positive end expiratory pressure. sion of the newborn characterized by hypoplastic
Tracheal masses: unexpected growth within a pulmonary vasculature from pulmonary hypo-
trachea; uncommon in children. plasia, which produces a relatively fixed level of
Tracheal occlusion: placing a tracheal plug in utero pulmonary hypertension.
into the fetus for a period of time to promote
lung growth. V
Tracheoesophageal fistula (TEF): a form of Validity: closeness to the truth.
esophageal atresia involving the connection be- Valleculae: spaces between the base of tongue and
tween the esophagus and the trachea. It can lead the epiglottis.
to severe pulmonary complications requiring a Vallecular cysts: a closed sac or pouch that con-
multidisciplinary approach to manage both tains fluid, semifluid, or solid material, found
digestive and respiratory malformations. in the vallecula.
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Glossary 561
Valvotomy: cardiac surgical procedure that con- Vibration: chest physiotherapy technique per-
sists of division of the valve leaflets or valve formed by gently shaking the chest wall with
replacement. hands or a mechanical device during expiration
Valvuloplasty: cardiac procedure wherein a to help mobilize secretions by oscillating the
catheter with a balloon at the tip is passed into airways and increasing expiratory flow rates.
the valve orifice and inflated to enlarge the Viscous: sticky, gummy, gelatinous mucus that
opening. blocks peripheral airways and is difficult to
Variable decelerations: most common form of de- expectorate.
celerations and represent umbilical cord com- Vitamin A (retinol): essential for the optimal
pression; no temporal relationship to the onset growth of cells and tissues. A deficiency may
of the contraction. contribute to the development of bronchopul-
Vascular endothelial growth factor (VEGF) monary dysplasia.
inhibitors: intravitreal (into the eye) medication Vocal fold paralysis: interruption of laryngeal nerve
that reduces the effect of VEGF on the develop- impulse, which controls vocal cord movement.
ing retina, halting the development of retinopa- Vocal fold nodules: callus-like lesions that develop
thy of prematurity. at the junction between the anterior and middle
Vascular resistance: resistance to flow that must be third of the vocal folds.
overcome in order to push blood through the Volume-control ventilation: delivers a consistent
circulatory system. volume with each breath, which allows for better
Venoarterial extracorporeal membrane oxygenation: control of minute ventilation.
form of extracorporeal support in which two Volume-targeted ventilation: allows clinicians to
large cannulas are inserted by a surgeon, one deliver a pressure-style breath while targeting a
into the right internal jugular vein and a second specific tidal volume.
into the right common carotid artery. The Volutrauma: overdistension of the lung, causing
cannulas are connected to the extracorporeal tissue injury.
membrane oxygenation circuit, creating a car- Volvulus: twisting of the bowel on itself, causing
diopulmonary bypass system that parallels the obstruction.
native cardiopulmonary system. Vomer: posterior aspect of the nasal septum.
Venovenous extracorporeal membrane oxygena-
tion: a double-lumen cannula is placed by the W
surgeon in the right internal jugular vein to Westley croup score: tool commonly used to char-
remove deoxygenated blood from the right acterize the severity of respiratory impairment in
atrium, cycle the blood though an artificial children with croup.
lung oxygenator, and then pump it back into Wet drowning: when the laryngeal cords no longer
the right atrium where the patient’s native contract, typically after a person loses con-
heart will be responsible for pumping the blood sciousness, and fluid is aspirated into the lungs.
throughout the body. Withholding resuscitation efforts: a conscious deci-
Ventilation: transport of gas in and out of the sion not to initiate some or all forms of life-
lungs. sustaining therapy after delivery; may be appro-
Ventilator-associated pneumonia (VAP): pneumonia priate in cases in which gestation, birth weight,
that occurs in patients being given mechanical and/or congenital anomalies are associated with
ventilation; term does not imply that ventilation high mortality and poor outcomes.
is the cause of the pneumonia Work of breathing (WOB): force generated by a
Ventricular septal defect (VSD): opening in the in- patient to overcome the frictional resistance and
traventricular septum that causes a connection static elastic forces that oppose lung expansion.
between the right and left ventricles.
Vestibular stenosis: constriction or narrowing of X
the soft tissue in the nares; can develop as an Xanthines: pharmacological stimulants, classified
uncommon consequence of using nasal prongs. as bronchodilators, although they are less potent
Viability: ability to survive outside of the uterus. than beta-2 agonists.
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2831_Index_563-588 28/03/14 3:30 PM Page 563
Index
Note: Page numbers followed by “b” denote boxes; “f” denote figures; “t” denote tables.
564 Index
of subglottis, 249–251 Allergic bronchopulmonary aspergillosis Aorta
of supraglottis, 244––247. See also (ABPA), in cystic fibrosis, 359 coarctation of, 271–273, 271f. See also
Supraglottis, abnormalities of treatment of, 374–375 Coarctation of aorta
of trachea and bronchi, 251–255. See Allergy testing, in asthma diagnosis, 322 development of, 36, 36f
also Trachea, abnormalities of Alveolar edema, complicating overriding VSD, in tetralogy of Fallot,
Airway clearance techniques (ACTs) bronchopulmonary dysplasia, 282
active cycle of breathing in, 363, treatment of, 126 Aortic arch, double, 273–274, 273f
364–365, 364f Alveolar phase, of lung development, 33t, Aortic stenosis, 268–270, 268f
by age appropriateness, 360t 35, 35f cardiac auscultation in, 263t
autogenic drainage as, 367, 367f Alveolar sacs, in children vs. adults, 6 Apgar scores, 60, 60t
forced expiratory technique as, Alveolus(i) Apnea
363–364, 364f in children vs. adults, 4t, 5–6 in bronchiolitis, 382, 384
high-frequency chest wall oscillation consolidated, in pneumonia, 394 in congenital diaphragmatic hernia, 216
as, 361, 363, 363f Pores of Kohn in, significance of, 6 in newborn, primary versus secondary,
high-pressure positive expiratory proliferation of 52–53, 53f
pressure as, 367 in alveolar phase of development, 35 obstructive sleep
intrapulmonary percussive ventilation in children, 5–6, 35 nocturnal asthma and, 317
as, 367 Amnioinfusion, in meconium aspiration in Robin sequence, 243
oscillatory PEP as, 366–367, 366f syndrome prevention, 154–155 of prematurity (AOP)
percussion as, 360–361 Amplatzer Septal Occluder, in atrial bedside monitoring for, improving
positive expiratory pressure as, septal defect closure, 265 quality of, 115b
365–366, 365b Analgesia central, 113
postural drainage as, 360, 361, 362f in congenital diaphragmatic hernia clinical manifestations of, 114–115
vibrations as, 361 management, 222–223 course and prognosis of, 117–118, 117f
when to begin, 361b for intubation, 88 management and treatment of,
Airway edema, airflow limitation in Anatomical differences, between adults 115–117
asthma from, 310, 311f and children, 3–6, 4t mixed, 113
Airway hyperresponsiveness, airflow Anesthetics, inhaled, for status asthmaticus, obstructive, 113
limitation in asthma from, 311 345b pathophysiology of, 113–114
Airway inflammation Angioedema, epiglottitis and, 418 Apneustic breathing, in traumatic brain
in asthma, 311–312, 312f, 313b Angioplasty, balloon, for coarctation of injury, 484, 484f
biomarkers of, 322 aorta, 272 Apoptosis, from oxygen toxicity, 402
Airway management. See also Intubation Anti-IgE therapy, for asthma, 334 Applicability, of research, 20b
in acute asthma exacerbation, Anti-infectives, for pneumonia, 396–397 ARDS. See Acute respiratory distress
343–344 Antibiotics syndrome (ARDS)
for bacterial tracheitis, 427–428 for aspiration pneumonia, 460 Areflexia, in Guillain-Barré syndrome,
for croup, 425–426 for bacterial pneumonia, 396–397 438
for epiglottitis, 420–421 for bacterial tracheitis, 427 Arrhythmias, in Ebstein anomaly, 297
for juvenile myasthenia gravis, 442 for botulism, 444 management of, 298
during neonatal resuscitation, 54–56 for bronchiolitis, 390 Arterial blood gas (ABG) sampling
in upper airway burns, 463 inhaled for blood gas monitoring, 10–12, 11t,
Airway pressure release ventilation in cystic fibrosis management, 370 13t
(APRV) in pneumonia management, 397, contraindications to, 10–11
for acute respiratory distress syndrome, 398b, 398f errors in, 11–12
405–406, 406f for neonatal pneumonia, 179, 180 indications for, 10
to improve pulmonary blood flow, for pulmonary exacerbations in cystic for pulmonary hypertension in
295b fibrosis, 373 congenital diaphragmatic
Airway remodeling, airflow limitation in Anticholinergics hernia, 217
asthma from, 311 for acute asthma exacerbation, 340 Arterial blood gases (ABGs)
Airway resistance for asthma, 335 in acute asthma exacerbation
with endotracheal tube, 89 Anticholinesterase therapy, prophylactic, monitoring, 343
weaning and, 96 in myasthenia gravis, 441, 442 in acute respiratory distress syndrome
in healthy newborn and adult, 89 Anticoagulant system, for ECMO, 149 diagnosis, 402
increased, in bronchiolitis, 383, 388 Anticoagulants, for lung injury in smoke in apnea of prematurity, 113, 114f
Albuterol inhalation, 464–465 in asthma exacerbations, 326–327
for acute asthma exacerbation, 339 Antigens, foreign, in type I hypersensitivity in atelectasis, 168
for asthma, 335 response, 311, 312f, 313b in botulism, 444
for bronchopulmonary dysplasia, 126 Antihistamines, for asthma, 334 in CPAP monitoring in bronchiolitis,
in cystic fibrosis management, 368–369, Antileukotrienes 391
369t for acute asthma exacerbation, 341 in ECMO support, 148
for inhalation injuries, 464 for asthma, 334 in hyperoxia test, 280–281
Allergen-specific immunotherapy, for Antimicrobial therapy, for epiglottitis, management of, in high-frequency jet
asthma, 334 421 ventilation for pulmonary
Allergens Antioxidants, for bronchopulmonary interstitial emphysema, 172
airborne, as asthma triggers, 314–315 dysplasia, 125 in meconium aspiration syndrome,
bronchoconstriction induced by, Antipyretics, 396 153
asthma exacerbations from, Antitoxin, for botulism, 444 in monitoring mechanical ventilation
315–316 AOP. See Apnea of prematurity (AOP) for ARDS, 404
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normal, by age, 11t medical history in, 318, 319b vitamin supplementation for, 337
in oxygen therapy for ARDS, 402 physical examination in, 318, 320 xanthines for, 333–334
in persistent pulmonary hypertension pulmonary function testing in, Asthma action plan, 329
of newborn, 139 320–321, 320f Asymmetric velocity profiles, in
target, in congenital diaphragmatic in very young, 323b high-frequency oscillatory
hernia management, 220 dietary changes for, 337 ventilation, 407
traumatic brain injury and, 486, 488, differential diagnosis of, 323, 323t Ataxic breathing, in traumatic brain
489–490 exacerbations of, 309, 326–328, 327t, injury, 484, 484f
values for, during neonatal mechanical 338–345. See also Status Atelectasis
ventilation asthmaticus definition of, 167
adjustments for, 95t anticholinergics for, 340 in near-drowning, 456, 457
weaning and, 99 antileukotrienes for, 341 treatment for, 459
Arterial oxygen saturation (SaO2), pulse arterial blood gases in monitoring in premature infants, 166–170
oximetry measuring, 10, 11b of, 343 anatomic factors contributing to,
Arterial switch operation, for transposition corticosteroids for, 340 167, 167b
of great arteries, 290 discharge after, 341 clinical manifestations of, 167–168
Arteries, great, transposition of, 288–291, early treatment of, 339 course and prognosis of, 170
288f. See also Transposition of emergency department management management and treatment of,
great arteries (TGA) of, 339–341 168–170, 169t
Aryepiglottic folds, 417 heliox for, 342–343 pathophysiology of, 167, 167b, 167f
Aryepiglottoplasty, for laryngomalacia, inhaled anesthetics for, 345b prevention of, 168
246 intensive care management of, Atelectrauma, definition of, 167
Ascites, in necrotizing enterocolitis, 200 341–345 Atopy, asthma and, 309, 314
ASD. See Atrial septal defect (ASD) intubation for, 343–344 Atresia
Asphyxia, neonatal, factors associated magnesium for, 340–341 pulmonary, in Ebstein anomaly,
with, 49b mechanical ventilation strategies for, 297–298
Aspiration, 467–470 344–345 tracheal, lung hyperplasia and, 218
chemical pneumonitis from, 470–472 noninvasive positive-pressure Atrial septal defect (ASD), 263–266
clinical decision-making for, 471t ventilation for, 342 adult presentation of, 265b
complicating intubation, guarding oxygen therapy for, 339 cardiac auscultation in, 263t
against, 487–488, 487f, 488b “rescue” therapy for, 335 clinical manifestations of, 264–265, 265b
definition of, 467 short-acting beta agonists for, closure of, 265
foreign body, 468–470, 468f 339–340 coronary sinus type, 264
of gastric secretions, 474–475 triggers of, 315–317 course and prognosis of, 266
of oral secretions, 472–474 exercise-induced, 309 definition of, 263
silent, 473 management of, 331b management and treatment of, 265–266
Aspiration pneumonia, in near-drowning, herbal therapies for, 336, 336b ostium primum, 264
456 hospitalizations for, 346 ostium secundum, 264
clinical manifestations of, 457 infants with, influenza vaccinations for, pathophysiology of, 264, 264f
treatments for, 460 intramuscular versus intranasal, sinus venosus type, 264
Aspiration pneumonitis, respiratory 346b Atrial septostomy, for transposition of
system effects of, 483 lung function and, 347 great arteries, 290, 290f
Assent, in clinical ethics, 511 management and treatment of, 328–345 Atrioventricular canal type ventricular
Assist-control ventilation, 93, 94f controlling asthma triggers in, septal defect, 266
Asthma, 307–354 328–330 Atrium, development of, 36, 36f
acupuncture for, 337 long-term, goals of, 328b Auscultation, cardiac
airway inflammation in, 311–312, 312f, nonpharmacological, 336–338 for acyanotic heart defects, 263, 263t
313b peak expiratory flow monitoring in, for cyanotic heart defects, 281t
atopy and, 309, 314 329–330, 329f Autism spectrum disorders (ASDs), 7b
breathing exercises for, 337–338 pharmacological, 330–335, 332t–333t Autogenic drainage (AD), in cystic fibrosis
caffeine for, 337 long-term control medications in, management, 367, 367f
causes of, 314–317 331–335 Autonomy, 505, 505f
genetic, 314 quick-relief medications in, 335 Autoregulation, of intracranial pressure,
clinical manifestations of, 317–328 manual therapy for, 337 486, 487f
control of, assessing, 338 mucus production increase in, 312 Axonal injury, diffuse, 483
corticosteroids for, inhaled, 331, natural history of, 312–313 Axons, 438b, 439f
332t–333t, 333 nocturnal, mechanisms of, 316–317 Aztreonam, in cystic fibrosis management,
cost of, 346–347 “outgrowing,” 347 370
cough variant, 321b pathophysiology of, 310–317
course and prognosis of, 346–347 prevalence of, 309 B
cromones for, 333 risk factors for, 309–310 B cells, in type I hypersensitivity response,
definition of, 308 severity of, classification of, 324, 311, 312f, 313b
diagnosis of, 318–323 324t–325t, 326 Bacteria, causing pneumonia, 393
allergy testing in, 322 stages of, treatments by, 330t Bacterial laryngotracheobronchitis, 426.
biomarkers of inflammation in, 322 triggers of, 314–317 See also Bacterial tracheitis
bronchoprovocation testing in, control of, 328–330 Bacterial pneumonia, 393, 395, 395f,
321–322 environmental, 314–315 395t. See also Pneumonia,
key indicators for considering, 318b for exacerbation, 315–317 bacterial
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566 Index
Bacterial tracheitis, 426–428 Blood flow, pulmonary to systemic, in clinical manifestations of, 383–385,
clinical features of, 417t atrial septal defect, 265 384t, 385t
clinical manifestations of, 426–427 Blood gas monitoring course and prognosis of, 393
course and prognosis of, 428 arterial blood gas sampling in, 10–12, diagnostic testing for, 384–385
management and treatment of, 427–428 13t. See also Arterial blood gas evaluation/treatment of, guidelines for,
pathogens causing, 426b (ABG) sampling 385t
pathophysiology of, 426 capillary blood gas sampling in, 12, 13t management and treatment of, 385–392
Ball-valve obstruction of airways, by indwelling peripheral artery catheter, antibiotics in, 390
meconium, 152, 152f 13t bilevel positive airway pressure in,
Balloon angioplasty, for coarctation of indwelling umbilical artery catheter, 391–392
aorta, 272 13t chest physiotherapy in, 389–390
Balloon catheter, in upper airway foreign in patient assessment, 10–12, 11t, 12b, continuous positive airway pressure
body removal, 470 13t, 14b in, 391
Balloon dilation, for subglottic stenosis, transcutaneous, 12, 13t epinephrine in, 389, 389t
249 Blood transfusions, for apnea of fluid management in, 390
Balloon valvuloplasty prematurity, 116 glucocorticoids in, 390
for aortic stenosis, 269 Body positioning. See Patient positioning helium-oxygen therapy in, 388, 388t
for pulmonic stenosis, 270 Boswellia extract, for asthma, 336b hypertonic saline solution in, 389
Barbiturate coma, in cerebral perfusion Botulism, 443–445 inhaled bronchodilator therapy in,
pressure management, 489 overview of, 435t 388–389
Barium swallow, modified, in respiratory Botulism immune globulin (BIG), for mucus clearance in, 386
management of spinal cord botulism, 444 noninvasive positive pressure
injury, 494 BPD. See Bronchopulmonary dysplasia ventilation in, 391
Beclomethasone diopropionate HFA (BPD) oxygen therapy in, 386–388, 386f,
(QVAR), for asthma, 332t Bradycardia 387t
Bedrest, in prevention of preterm in apnea of prematurity, 114, 114f patient positioning in, 390
delivery, 74 definition of, 47 ribavirin in, 390–391
Bell’s staging criteria, modified, for in pulmonary interstitial emphysema, suctioning in, 386
necrotizing enterocolitis, 202t 171 pathophysiology of, 383
Beneficence, as bioethical principle, 505f, in response to hypoxia in preterm prevention of, 392
506 infants, 114 risk factors for, 382–383
Benzodiazepines, for sedation for Brain Bronchoalveolar lavage (BAL), 396
intubation, 344 fetal development of, 36 Bronchoconstriction
Best-interest standard, in clinical ethics, herniation of, 486, 486f airflow limitation in asthma from,
510 injury to 310–311, 311f
Best Pharmaceuticals for Children Act in preterm infant, measures to allergen-induced, asthma exacerbations
(BPCA), 14 prevent, 76 from, 315–316
Beta agonists traumatic, 482–491. See also Bronchodilators
long-acting, for asthma, 334–335 Traumatic brain injury (TBI) for bronchopulmonary dysplasia, 126
short-acting, for exercise-induced protective barrier of, 482, 483f for cystic fibrosis, 368–369, 369t
asthma, 331b ventricles of, bleeding in, in for inhalation injuries, 464
Bicarbonate (HCO3) in blood, assessment intraventricular hemorrhage, inhaled
of, blood gas monitoring in, 187 for bronchiolitis, 388–389
10–12, 11t Brainstem for pneumonia, 397
Bicuspid aortic valve, aortic stenosis in control of ventilation, 113 Bronchoprovocation testing (BPT), in
from, 268 development of, 36 asthma diagnosis, 321–322
Bidirectional Glenn procedure, for Breath-actuated nebulizer, in inhalation Bronchopulmonary dysplasia (BPD),
hypoplastic left heart syndrome, medication delivery, 371, 371t 118–128
293–294, 293f, 293t Breath-delivery ventilator types, 90, 90f clinical manifestations of, 121–122,
Bile duct obstruction, in cystic fibrosis, 359 Breath-enhanced nebulizer, in inhalation 122f
Bilevel positive airway pressure (BiPAP), medication delivery, 371, 371t course and prognosis of, 126–128
in bronchiolitis management, Breathing definition of, current, 119, 119t
391–392 active cycle, in cystic fibrosis incidence of, 119, 119b
Bioethics. See also Ethics management, 363, 364–365, management and treatment of, 122–126
definition of, 504 364f antioxidants in, 125
principles of, 504–506, 505f apneustic, 484, 484f bronchodilators in, 126
Biomarkers, of inflammation, in asthma ataxic, 484, 484f caffeine in, 125
diagnosis, 322 cluster, 484, 484f corticosteroids in, 124–125, 124b
Biparietal diameter, in determining disordered, sleep-related, in Duchenne diuretics in, 126
gestational age, 33 muscular dystrophy, 447 fluid restriction in, 126
Biventricular hypertrophy, in transposition periodic, in neonates, 113, 113b inhaled nitric oxide in, 125–126
of great arteries, 289 work of. See Work of breathing inositol in, 125
Blalock-Taussig shunt, for pulmonary (WOB) mast cell stabilizers in, 125
atresia in Ebstein anomaly, 298 Breathing exercises, for asthma, 337–338 mechanical ventilation strategies in,
Bleeding, spontaneous premature labor Breathing pattern, see-saw, 72 123–124
from, 67 Bronchial intubation, 173, 173b oxygen therapy in, 123
Blood cultures, in pneumonia diagnosis, Bronchiectasis, 358, 358f, 359f prevention strategies in, 123, 123b
396 Bronchiolitis, 382–393 pulmonary edema treatment in, 126
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surfactant therapy in, 123 Cardiorespiratory monitor, home, in in pulmonary interstitial emphysema,
vitamin A in, 125 apnea of prematurity 171, 171f
new, pathophysiology of, 121 management, 117–118, 117f in respiratory distress syndrome,
old Cardiovascular support reticulogranular pattern in, 72,
pathophysiology of, 120–121 in extracorporeal membrane 74f
vs. new, 119 oxygenation, 148–149 in tension pneumothorax, 174, 175,
characteristics of, 120t in meconium aspiration syndrome, 156 176f
pathophysiology of, 120–121 in neonatal resuscitation, 56–57, 57f in tetralogy of Fallot, 283, 283f
in preterm infants, 102 in persistent pulmonary hypertension in transient tachypnea of newborn,
risk factors for, 119–120 of newborn, 142 158, 158f
Bronchoscopy, in bacterial tracheitis, 427 Catastrophic deterioration, in in transposition of great arteries
Bronchus, mainstem, in children vs. intraventricular hemorrhage, (TGA), 288, 288f, 289f
adults, 4t, 5 188 in truncus arteriosus, 299, 299f
Broselow Tape, for weight assessment, 8 CDH. See Congenital diaphragmatic Chest wall
Bubble CPAP, 84–85, 84f, 85t hernia (CDH) in children vs. adults, 4t, 6
neonatal, description of, 169t Central apnea of prematurity, 113 overly compliant, in respiratory
in resource-limited environments, 85b Central chemoreceptors, in control of distress syndrome, 71
Bubble positive expiratory pressure, 365b respiratory pattern, 113 Chest wall escharotomy, 465
Budesonide/formoterol (Symbicort), for Cerebral blood flow, clinical factors Cheyne-Stokes respirations, 484, 484f
asthma, 333t altering, 188b Child(ren)
Budesonide (Pulmicort), for asthma, 332t Cerebral hemispheres, development of, 37 admitting to hospital, reasons for, 395b
Bulk flow ventilation, in high-frequency Cerebral perfusion pressure (CPP) anatomical differences between adults
oscillatory ventilation, 407 management, 488, 488t and, 3–6, 4t
Burns, calculating total body surface area first-tier therapy for, 488–489 autonomy and, 505
of, 467 second-tier therapy for, 489 normal ABG values for, 11t
Cerebrospinal fluid (CSF) drainage, in normal vital sign values for, 9t–10t
C cerebral perfusion pressure research in, acceptable risk in, 506b
Caffeine, for asthma, 337 management, 488–489 school-age. See School-age child(ren)
Caffeine citrate Cerebrum social and language developmental
for apnea of prematurity, 115–116 development of, 36–37 milestones for, 7
for bronchopulmonary dysplasia, 125 functions of, 37 Childhood, age ranges in, 3b
Canalicular phase, of fetal lung Cervical spine, 492f Choanal atresia, 239–241, 240f, 241f
development, 33t, 34–35, 34f injuries to, 492–493 Choanal stenosis, 241
Cannula(s) from intubation, minimizing, 487 Chorioamnionitis, pneumonia in
ECMO, 147–148, 148f CHARGE syndrome, 239 newborn and, 178
nasal. See Nasal cannula Chemical pneumonitis, 470–472 Chorionic villi, in fetal circulation, 37
Capillary blood gas (CBG) sampling, 12, from meconium aspiration, 152 Chronic lung disease (CLD)
13t Chemoreceptors, in control of respiratory bronchopulmonary dysplasia as, 118
Capnography, in respiratory management pattern, 113–114 definition of, 118
of spinal cord injury, 493 Chest compressions, in neonatal Chylothorax, complicating coarctation
Capnometry, in traumatic brain injury resuscitation, 56–57, 57f repair, 272
management, 490 Chest physiotherapy (CPT) Ciclesonide (Alvesco), for asthma, 332t
Carbon dioxide (CO2) for atelectasis, in near-drowning, 459 Circadian modulation, of respiratory
effect on cerebral blood flow, 191, in atelectasis prevention, 169 function, nocturnal asthma and,
191t in bronchiolitis management, 389–390 316
end-tidal, monitoring of, in traumatic for direct lung inhalation injury, 464 Circulation, fetal, 37–38, 37b, 38f, 137
brain injury management, 490, for mucociliary clearance, 437t changes to
490b Chest radiography (CXR) at delivery, normal, 38–39, 39t,
Carbon monoxide poisoning, from in acute respiratory distress syndrome, 137–138, 194–195, 194f
smoke inhalation, 465–466 400f, 401 during persistent pulmonary
Carboxyhemoglobin in atelectasis, 168 hypertension of newborn, 138
in carbon monoxide poisoning, 465–466 in atrial septal defect, 265 Cirrhosis, liver, 359
signs and symptoms of, 466t in bacterial tracheitis, 427 Cleft lip, abnormalities of nasal passages
Cardiac catheterization, in atrial septal in bronchiolitis, 384–385 and nasopharynx with, 241,
defect closure, 265 in bronchopulmonary dysplasia, 122f 241f
Cardiac death, organ donation after, in cystic fibrosis monitoring, 358f, 359 Cleft palate, in Robin sequence, 242, 243f
ethical issues involving, 519–520 in Ebstein anomaly, 297, 297f Clinical ethics, 509–513
Cardiac insufficiency, in congenital in hypoplastic left heart syndrome, assent and, 511
diaphragmatic hernia, 217 292, 292f best-interest standard and, 510
Cardiogenic mixing, in high-frequency in meconium aspiration syndrome, clinical scenarios with implications for,
oscillatory ventilation, 407 153, 153f 514–520
Cardiomegaly, in persistent pulmonary in patent ductus arteriosus, 197 confidentiality and, 510
hypertension of newborn, 139 before and after ligation, 198f futility and, 511–512
Cardiopulmonary development, fetal, in persistent pulmonary hypertension goals of care and, 511
31–44 of newborn, 139 hospital ethics committees and, 513,
case studies on, 42–43 in pneumomediastinum, 177, 177f 513f
implications of, on neonatal course, 41, in pneumonia, 179, 179f, 395, 395f informed consent and, 510–511
42t in pneumopericardium, 178, 178f moral distress and, 512
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Clinical patient care, ethical principles course and prognosis of, 225–226 antenatal, in respiratory distress
guiding, 504–506, 505f incidence of, 214–215 syndrome, 75
Clinical scenarios with ethical malrotation with, 216 for bacterial tracheitis, 427
implications for pediatric management and treatment of, 217–224 for bronchopulmonary dysplasia,
respiratory care, 514–520 analgesia and paralysis in, 222–223 124–125, 124b
Clostridium botulinum, botulism from, in delivery room, 219, 219b for croup, 424–425
443 extracorporeal membrane for epiglottitis, 421
Clostridium tetani, tetanus from, 442 oxygenation in, 223, 223b for hydrocarbon aspiration, 471
Cluster breathing, 484, 484f inotropes in, 222 for inhalation injuries, 465
Coagulation, disseminated intravascular postoperative, 224 inhaled, for asthma, 331, 332t–333t,
(DIC), in necrotizing prenatal options for, 218–219 333
enterocolitis, 200 preoperative, 219–220 maternal, in transient tachypnea of
Coarctation of aorta, 271–273, 271f primary repair versus reconstruction newborn prevention, 158
cardiac auscultation in, 263t in, 224, 224f Cost, of asthma, 346–347
clinical manifestations of, 272 pulmonary vasodilators in, 221–222, Cough variant asthma, 321b
course and prognosis of, 272–273 222b Counseling, prenatal, for congenital
management and treatment of, 272 surfactant in, 221 diaphragmatic hernia, 218
pathophysiology of, 271–272 surgical, 223–224, 224f CPAP. See Continuous positive airway
Cockroaches, as asthma trigger, 315 ventilation strategies in pressure (CPAP)
Cognition, shared, in neonatal conventional, 220–221 Cranial vault, pressure in, 485. See also
resuscitation, 59b high-frequency, 221 Intracranial pressure (ICP)
Colistin, in cystic fibrosis management, previous, 220 Craniectomy, decompressive, in cerebral
370 patent ductus arteriosus with, 215 perfusion pressure management,
Collateral ventilation, in forced patent foramen ovale with, 215–216 489
expiratory technique, 364 pathophysiology of, 215–216 Craniosynostosis, nasal obstruction in,
Collumella, nasal stents and, 240 in prematurity, 225b 241
Coma prenatal findings in, 216 Cricoid pressure
barbiturate, in cerebral perfusion Congenital myasthenia gravis, 441 in children, 6
pressure management, 489 Congenital vascular malformations, in preventing aspiration during
Glasgow Coma Scale and, 484, 485t airway obstruction from, 244 intubation, 487, 487f
Communication Conscientious refusal, in clinical ethics, 512 Cricoid ring, in children vs. adults, 3, 4t
critical language in, 176b Consent, informed, in clinical ethics, Cricoid split, for subglottic stenosis, 250
on management and treatment to 510–511 Cricothyroid membrane, in children vs.
health care team, 420b Consolidated alveoli, in pneumonia, 394 adults, 3, 4t
Compassion fatigue, 512 Consumerism, in decision making, 517, Cricothyroidotomy
Competency, professional, duty to 517b emergency, in upper airway foreign
obtain, 507 Continuous positive airway pressure body removal, 470
Complete atrioventricular septal defects, (CPAP) in epiglottitis, 420, 421
268 in bronchiolitis management, 391 Cricotracheal resection, for subglottic
Complete vascular rings, double aortic bubble, 84–85, 84f, 85t stenosis, 250
arch as, 273 neonatal, description of, 169t Critical opening pressure, 203
Compliance in resource-limited environments, Cromolyn sodium
with pediatric patients, enhancing, 505b 85b for asthma, 333
static, calculation of, 404 complications of, 85 for bronchopulmonary dysplasia, 125
Computed tomography (CT) scans, in components of, 83–84, 84f Cromones, for asthma, 333
cystic fibrosis monitoring, 359f, nasal. See Nasal continuous positive Croup, 422–426
395 airway pressure (NCPAP) bacterial, 426. See also Bacterial
Conception, definition of, 32 in patent ductus arteriosus management, tracheitis
Concurrent care, 530 198 clinical features of, 417t
Conducting airways, in children vs. for preterm infant, 76, 77b clinical manifestations of, 422–423
adults, 4t, 5 for respiratory distress syndrome, 82–83 course and prognosis of, 426
Conduit, pulmonary artery, pulmonary variable-flow, 84, 85t laboratory and diagnostic procedures
valve replacement via, 284 neonatal, description of, 169t in, 423
Confidentiality, in clinical ethics, 510 ventilator, 84, 85t management and treatment of,
Congenital abdominal defects, 213–235. neonatal, description of, 169t 423–426
See also Abdominal defects Contracture, in limb-girdle muscular airway management in, 425–426
Congenital anomalies, 237–305 dystrophy, 445b corticosteroids in, 424–425
airway, 237–259. See also Airway Contusion heliox therapy in, 425
abnormalities brain, 483 inhaled medications in, 424
extreme, neonatal resuscitation with, pulmonary, respiratory system effects oxygen therapy in, 424
ethical implications of, 514–516, of, 483 past medical history in, 422
515t Coronary sinus type atrial septal defect, pathophysiology of, 422
heart defects as, acyanotic, 261–277. 264 pseudomembranous, 426. See also
See also Acyanotic heart defects Corticosteroids Bacterial tracheitis
neonatal resuscitation and, 58–59 for acute asthma exacerbation, 340 respiratory distress in, 423, 423t
Congenital diaphragmatic hernia (CDH), for acute respiratory distress spasmodic, 423b
214–226 syndrome, from near-drowning, Crouzon’s disease, nasal obstruction in,
clinical manifestations of, 216–217 460–461 241
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Crown-to-rump measurement, in course and prognosis of, 375–376 Demyelination polyradiculoneuropathy,
determining gestational age, 33 diagnosis of, 359 in Guillain-Barré syndrome, 438
Cryotherapy, for retinopathy of management and treatment of, 359–375 Dendrites, 438b, 439f
prematurity, 206 adherence to therapy in, 372, 373b Dendritic cells, in type I hypersensitivity
Culture(s) airway clearance techniques in, response, 311, 312f, 313b
blood, in pneumonia diagnosis, 396 360–367. See also Airway Depression, neonatal, factors associated
sputum, in pneumonia diagnosis, 396 clearance techniques (ACTs), with, 49b
Cushing’s triad, 486 in cystic fibrosis management Development, stages of, 32–33
CXR. See Chest radiography (CXR) bronchodilators in, 368–369, 371t Dexamethasone
Cyanosis for complications, 374–375 for bronchopulmonary dysplasia, 124
in apnea of prematurity, 112 disease-modifying therapy in, for upper airway injury, with
in asthma exacerbation, 326 371–372 inhalation injuries, 463
asymptomatic, in truncus arteriosus, 299 dornase alfa in, 369–370, 371t Diaphragm
in bronchiolitis, 384 for end-stage lung disease, 375 in children vs. adults, 4t, 5
in DiGeorge syndrome, 271b exercise in, 368, 369b pacing of, in respiratory management
in Ebstein anomaly, 297 hypertonic saline in, 370, 371t of spinal cord injury, 494
in Eisenmenger complex, 266 infection control in, 372, 372t pressure of, during gastroschisis
in hydrocarbon aspiration, 471 inhalation therapies in, 368–371. reduction, 227, 228
in hypoplastic left heart syndrome, 292 See also Inhalation therapies, in rupture of, respiratory system effects
in lipoid aspiration, 472 cystic fibrosis management of, 484
in meconium aspiration syndrome, inhaled antibiotics in, 370, 371t Diaphragm fluoroscopy, in respiratory
152, 153b lung transplantation in, 375 management of spinal cord
in near-drowning, 457 mucolytics in, 369–370, 371t injury, 494
in newborn post-resuscitation, 59. See working with physical therapy in, Diaphragmatic hernia, congenital,
also Cyanotic heart defects 369b 214–226. See also Congenital
in oropharyngeal separation, 473 meconium ileus in, 152b diaphragmatic hernia (CDH)
paradoxical, in choanal atresia, 240 pathophysiology of, 357, 357f Dietary changes, for asthma, 337
in pneumomediastinum, 177 Cystic fibrosis transmembrane Diffuse axonal injury, 483
in pneumopericardium, 178 conductance regulator (CFTR) DiGeorge syndrome, aortic coarctation
in pulmonic stenosis, 270 gene, 356 in, 271b
refractory, in ARDS, 401 mutations of, classes of, 356t Disaster ethics, 509
in respiratory distress syndrome, 73 Cystic hygroma, 244 Discontinuing neonatal resuscitation, 59
reverse, in transposition of great Cytochrome oxidase, cyanide binding to, Disruption in fetal development,
arteries, 289 466 gastroschisis as, 226
in spontaneous pneumothorax, 174b Disseminated intravascular coagulation
in tetralogy of Fallot, 282, 283, 284 D (DIC), in necrotizing
in total anomalous pulmonary venous Dead donor rule, 520 enterocolitis, 200
return, 287 Dead space ventilation, in respiratory Distraction, for enhancing compliance,
in tracheoesophageal fistula, 252 distress syndrome, 71 505b
in upper airway burns, 462 Death Distress, moral, in clinical ethics, 512
Cyanotic congenital heart disease, cardiac, organ donation after, ethical Diuretic therapy, in near-drowning
neonatal resuscitation and, 59 issues involving, 519–520 management, 459
Cyanotic heart defects, 279–305 location of, 538–539 Diuretics, for bronchopulmonary
cardiac auscultation for, 281t Deceleration phase of labor, 46–47 dysplasia, 126
Ebstein anomaly as, 296–298, 296f Decelerations DNase. See also Dornase alfa (rhDNase,
hypoplastic left heart syndrome as, early, in fetal heart rate, 47, 48f Pulmozyme)
281f, 291–296. See also late, in fetal heart rate, 47, 48f for aspiration pneumonia, 460
Hypoplastic left heart syndrome variable, in fetal heart rate, 47, 48f for atelectasis, 459
(HLHS) Deception, for enhancing compliance, for cystic fibrosis, 369–370
tetralogy of Fallot as, 282–285, 282f. 505b Do not attempt resuscitation (DNAR)
See also Tetralogy of Fallot Decision-making order, 532f, 537–533
(TOF) medical, emancipated minors and, Documentation, of Apgar scores, 60
total anomalous pulmonary venous 506b Donation, organ
return as, 285–288. See also shared, 517 after cardiac death, ethical issues
Total anomalous pulmonary Decompressive craniectomy, 489 involving, 519–520
venous return (TAPVR) Deliberative decision-making, 517, 517b discontinuation of mechanical
transposition of great arteries as, Delivery ventilation and, 534
288–291. See also Transposition clinical findings of congenital Donation after cardiac death (DCD),
of great arteries (TGA) diaphragmatic hernia at, ethical issues involving,
truncus arteriosus as, 298–300, 298f 216–217, 216f 519–520
Cyst(s) congenital diaphragmatic hernia Doppler interrogation, in acyanotic heart
subglottic, 251 management in, 219, 219b defects diagnosis, 263
vallecular, 246, 246f fetal circulation changes at, 38–39, 39t Dornase alfa (rhDNase, Pulmozyme).
Cystic fibrosis (CF), 355–380 fetal monitoring during, 47 See also DNase
clinical manifestations of, 357–359, respiratory distress syndrome in cystic fibrosis management, 369–370
358f, 359f management in, 75–76, 75b, 76b Double aortic arch, 273–274, 273f
gastrointestinal, 357–358, 358f suctioning at, evidence on, 154b Down syndrome. See Trisomy 21 (Down
pulmonary, 358–359, 358f, 359f Demyelination, definition of, 438 syndrome)
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570 Index
Drainage Electromyography (EMG), in Guillain- sputum, as biomarkers of airway
autogenic, in cystic fibrosis Barré syndrome diagnosis, 439 inflammation, 322
management, 367, 367f Emancipated minors, medical decision- Epidural hematoma, 483, 483f
peritoneal, for necrotizing enterocolitis, making and, 506b Epiglottis, in children vs. adults, 3, 4t
203 Embryonic phase, of fetal lung Epiglottitis, 246, 417–422
Drooling, in epiglottitis, 418, 419b development, 33–34, 33t, 34f adult, 422b
Drowning, 454. See also Near-drowning Embryonic stage of development, airway and respiratory symptoms of,
definition of, 455 definition of, 32 419
secondary, 455–456 Emergencies, public health, professional airway stabilization and management
wet vs. dry, 455 ethics and, 509 for, 420–421
Dry drowning, 455 Empyema, 179 antimicrobial therapy for, 421
Duchenne’s muscular dystrophy (DMD), Encephalopathy, hypoxic-ischemic, clinical features of, 417t
445–447 induced hypothermia of clinical manifestations of, 418–419
Ductus arteriosus, 193 newborn for, 50–51 corticosteroids for, 421
closure of End-of-life care, 525–544 course and prognosis of, 421–422
failure of, 195 discontinuing mechanical ventilation extubation for, 421
functional, 193, 194–195, 194f in, 533–534 George Washington and, 418b
in fetal circulation, 37b, 38, 38f do not attempt resuscitation orders intensive care unit management of,
patent, 193–199, 194f. See also Patent and, 531–533, 532f 421
ductus arteriosus (PDA) ethical issues in, 518–520 laboratory test results in, 419
Ductus venosus, in fetal circulation, 37, goals of, framing discussion about, management and treatment of,
37b, 38f 528–529 420–421
Dust mites, as asthma trigger, 315 location of death and, 538–539 noninfectious causes of, 418
Dysfunctional swallowing, 472 managing secretions in, 537 oxygen therapy for, 420
Dysmotility, foregut, in congenital palliative care in, 527, 527t past and recent medical history in, 419
diaphragmatic hernia survivors, sedation in, 537 pathogens causing, 418
225 supporting family in, 539 pathophysiology of, 417–418
Dysphagia, 418, 419b supporting healthcare team in, 539–540 subjective signs of, 418–19
Dysphonia, 419, 419b treating dyspnea in, 535–537 Epiglottoplasty, 246
Dyspnea End-tidal carbon dioxide monitoring, in Epinephrine
after terminal extubation traumatic brain injury in bronchiolitis management, 389, 389t
narcotics for, rule of double effect management, 490, 490b for cardiovascular support, in neonatal
and, 518–519 Endobronchial masses, 253 resuscitation, 57
treatment of, 535–537, 535f Endocarditis, infective, from aortic racemic
in asthma, 310 stenosis, 270 for croup, 424
in epiglottitis, 418–419, 419b Endoderm, respiratory development in upper airway foreign body
from, 33 management, 469
E Endoscopy for upper airway injury, with
Early decelerations, in fetal heart rate, 47, in epiglottitis diagnosis, 419, 419f inhalation injuries, 463
48f in infectious airway disease diagnosis, Epithelial cells, in type I hypersensitivity
Ebstein anomaly, 296–298, 296f 416 response, 311, 312f, 313b
Echocardiogram in laryngomalacia diagnosis, 245 Epithelialization, in delayed closure of
in acyanotic heart defect diagnosis, 262 Endotracheal intubation. See Intubation, omphalocele, 229
in atrial septal defect, 265 endotracheal Equal pressure points, in forced
in congenital diaphragmatic hernia, 216 Endotracheal tube (ETT) expiratory technique, 363–364,
in cyanotic heart defect diagnosis, 281 airway resistance with, 89 364f
in Ebstein anomaly, 297 depth placement determination for, 17 Equipment
in hypoplastic left heart syndrome with meconium aspirator, technique for neonatal resuscitation, 50, 50b
diagnosis, 292 using, 154 respiratory care, selection of, 16–17
in patent ductus arteriosus, 197 position of, head rotation and, 5f Errors, medical, ethical duty to prevent,
in tetralogy of Fallot diagnosis, 283 size selection of 507–509
in total anomalous pulmonary venous calculation for, 16 Escharotomy, chest wall, 465
return, 287 for neonates, 17t Eschars, definition of, 465
in truncus arteriosus diagnosis, 299 uncuffed, as seal in small child, 3 Esophageal atresia, 251–252
ECMO. See Extracorporeal membrane upsizing of, for growing babies, 89b Ethics, 503–524. See also Bioethics
oxygenation (ECMO) Enteral feeding, for oral motor clinical, 509–513. See also Clinical
Edema dysfunction, 473–474, 473b ethics
airway, airflow limitation in asthma Enterocolitis, necrotizing, 199–204. See disaster, 509
from, 310, 311f also Necrotizing enterocolitis end-of-life care and, 518–520
pulmonary. See Pulmonary edema (NEC) health policy, 513
Elastic recoil, of lungs, in children vs. Environmental delivery system, for professional, 506–509. See also
adults, 4t, 6 oxygen delivery for premature Professional ethics
Electrocardiogram (EKG) infants, 81t ETT. See Endotracheal tube (ETT)
in atrial septal defect, 265 Environmental factors, sleep-related, in Eucalyptol, 1.8-cineol, for asthma, 336b
in Ebstein anomaly, 297 nocturnal asthma, 317 Euthanasia, 537
in tetralogy of Fallot, 283 Eosinophils Evidence-based medicine, 18, 20b, 21–24
in total anomalous pulmonary venous in inflammatory pathway of asthma, definition of, 18
return, 287 313b steps for, 20b
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Exacerbations Extrathoracic trachea, in children vs. Fetal tachycardia, definition of, 47
asthma, 309, 326–328, 327t, 338–345. adults, 3, 4t, 5 Fetoscope endoluminal tracheal occlusion,
See also Asthma, exacerbations Extrauterine life, transition to, for congenital diaphragmatic
of resuscitation of newborn hernia, 218b
pulmonary, in cystic fibrosis, therapy during, 45–63. See also Fever, therapeutic, 396b
for, 373–374, 373b Neonatal resuscitation Fibroproliferative stage, of acute
Excision of sac, in delayed closure of Extravasation, in neurogenic pulmonary respiratory distress syndrome,
omphalocele, 229 edema development, 496 456
Exclusivity, in pediatric drug Extremity, lower, paralysis of, Fibrotic stage, of acute respiratory
investigations, 14 complicating coarctation repair, distress syndrome, 400, 400t
Exercise(s) 272 Fistula, tracheoesophageal, 251–253,
breathing, for asthma, 337–338 Extubation 252f
in cystic fibrosis management, 368, in epiglottitis, 421 “Fixed” split S2
369t in pulmonary interstitial emphysema, 171 in atrial septal defect, 265
physical, for asthma, 338 terminal, 518 in pulmonic stenosis, 270
Exercise-induced asthma, 309 terminal weaning versus, 533–534 in total anomalous pulmonary venous
Exhaled breath condensate, as biomarker in traumatic brain injury, 490 return, 287
of airway inflammation, 322 Exudative stage, of acute respiratory Flaccid paralysis, in Guillain-Barré
Exogenous surfactant. See Surfactant, distress syndrome, 400, 400t, syndrome, 438
exogenous 456 FLM. See Fetal lung maturity (FLM)
Exploratory laparotomy, for necrotizing Exudative tracheitis, 253 Flow-inflating bag, for positive-pressure
enterocolitis, 202–203 ventilation, 55, 55t
Expressive language, 6 F Flow rate, for conventional mechanical
Extracorporeal life support (ECLS), Face, Legs, Activity, Cry, Consolability ventilation for RDS, 92–93
145–150. See also (FLACC), for pain assessment Fluid, distribution of, in body, patent
Extracorporeal membrane in infants, 8 ductus arteriosus and, 196
oxygenation (ECMO) Face mask, for oxygen delivery for Fluid management
Extracorporeal membrane oxygenation premature infants, 81t, 82 in near-drowning, 459
(ECMO) Failure to thrive, 287 in bronchiolitis, 390
for acute respiratory distress Family in pneumonia, 397
syndrome, from near-drowning, preparation of, for discontinuing Fluid restriction, for bronchopulmonary
461 mechanical ventilation, 534 dysplasia, 126
in acute respiratory distress syndrome supporting, in end-of-life care, 539 Flunisolide (Aerobid), 332t
management, 409 Family history, as asthma risk factor, 309 Flunisolide hemihydrate (Aerospan),
for asthma exacerbation, 345 Fatigue, compassion, 512 332t
for congenital diaphragmatic hernia, Femur, length of, in determining fetal Fluoroscopy, diaphragm, in respiratory
223, 223b age, 33 management of spinal cord
for meconium aspiration syndrome, Fetal bradycardia, definition of, 47 injury, 494
156 Fetal cardiopulmonary development, Fluticasone propionate (Flovent), 332t
for persistent pulmonary hypertension 31–44 Fluticasone propionate/salmeterol
of newborn, 145–150 implications of, on neonatal course, 41 (Advair Diskus; Advair HFA),
anticoagulation system for, 149 Fetal circulation, 37–38, 37b, 38f, 137 333t
blood products for, 149 changes to Fomites, in respiratory syncytial virus
cannulas for, 147–148, 148f at delivery, normal, 38–39, 39t, transmission, 383
cardiovascular support provided by, 137–138, 194–195, 194f Fontan procedure
148–149 during persistent pulmonary for Ebstein anomaly, 298
care of patient on, 148 hypertension of newborn, 138 for hypoplastic left heart syndrome,
circuits and equipment for, 147–148, in transposition of great arteries, 288 293f, 293t, 294
148f Fetal development stage Food-borne botulism, 443
complications of, 150, 151b cardiac development in, 35–36, 36f Foramen of Bodchalek, 215
decannulation in, 150 definition of, 32–33 Foramen ovale
fluid balance and, 149 lung development in, 33–35, 33t, 34f, in fetal circulation, 37, 37b, 38f
heaters for, 148 35f patent, 264
history of, 145 neurological development in, 36–37 with congenital diaphragmatic
initiation of, 146–147 Fetal heart rate (FHR), monitoring of, hernia, 215–216
neurological support provided by, 150 during labor and delivery, 47 Forced expiratory technique (FET)
oxygenators for, 148 Fetal lung fluid, secretion of, 34 in active cycle breathing, 364
patient selection criteria for, 145–146, Fetal lung maturity (FLM), assessing in cystic fibrosis management, 363–364,
145b lamellar body count in, 41 364f
pulmonary support provided by, lung profile test in, 40 Forced expiratory volume in 1 second
149–150 S/A ratio in, 40 (FEV1), 320
pump for, 148 shake test in, 40 Forced expiratory volume in 1 second
safety and monitoring devices for, Fetal monitoring, during labor and (FEV1)/forced vital capacity
148 delivery, 47 (FVC), 320
types of, 146, 146t, 147f Fetal scalp blood sampling, during labor Forced expiratory volume in 6 seconds
venoarterial, 146, 146t, 147f and delivery, 47 (FEV6), 320
venovenous, 146, 146t Fetal stress, spontaneous premature Forced vital capacity (FVC)
weaning from, 150 labor from, 67 in asthma assessment, 320
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in respiratory management of spinal Glenn procedure Heart
cord injury, 493–494 bidirectional, for hypoplastic left heart auscultation of, in acyanotic heart
spirometry values for, 436t syndrome, 293–294, 293f, 293t defect diagnosis, 263, 263t
Foreign antigen, in type I hypersensitivity for Ebstein anomaly, 298 in children vs. adults, 4t, 6
response, 311, 312f, 313b Glossoptosis, in Robin sequence, 242, 243 defects of
Foreign bodies, intranasal, 241–242 Glottic web, 248 acyanotic, 261–277. See also
Foreign body aspiration, 468–470, 468f Glottis Acyanotic heart defects
Fractional concentration of inspired abnormalities of, 247–249 cyanotic, 279–305. See also Cyanotic
oxygen (FIO2) recurrent respiratory papillomatosis heart defects
levels of, delivered to neonatal airway as, 247–248, 247f, 248b fetal development of, 35–36, 36f
via nasal cannula, 81t in children vs. adults, 3, 4t transplantation of, for hypoplastic left
oxygenation and, 94 definition of, 244, 245f, 247 heart syndrome, 294
titration of, during oxygen delivery in nodules of, 248–249 Heart rate
RDS, 79–80 paralysis of, 248 evaluation of, in delivery room, 52, 54f
Fractional exhaled nitric oxide (FeNO), Glucocorticoids fetal, monitoring of, during labor and
as biomarker of airway in acute respiratory distress syndrome delivery, 47
inflammation, 322 management, 408 Heated, humidified, high-flow nasal
Fractures, rib, respiratory system effects in bronchiolitis management, 390 cannula (HFNC) for oxygen
of, 484 in pneumonia management, 398 delivery, 387t
Fresh frozen plasma (FFP), for ECMO, during preterm labor, 41 in bronchiolitis, 387–388
149 Glycopyrrolate, in oropharyngeal for premature infants, 81t, 82
Functional residual capacity (FRC) aspiration management, 474 Heaters, ECMO, 148
in children vs. adults, 6 GM. See Germinal matrix (GM) Heimlich maneuver, in upper airway
in mechanical ventilation for Goals of care foreign body removal, 470
necrotizing enterocolitis, 203 in clinical ethics, 511 Helium-oxygen (heliox) therapy
Futility, in clinical ethics, 511–512 for end of life, framing discussion for acute asthma exacerbation,
about, 528 342–343
G Golden minute, for initial assessment and for bronchiolitis, 388, 388t
Gangliosides, antibodies against, in interventions of resuscitation, for croup, 425
Guillain-Barré syndrome, 438 51 Hemangioma, subglottic, 251
Gas stoves, as asthma trigger, 316 Gowers sign, in limb-girdle muscular Hematoma
Gastric secretions, aspiration of, 474–475 dystrophy, 445b epidural, 483, 483f
Gastroesophageal reflux disease Great arteries, transposition of, 288–291, subdural, 483, 483f
(GERD) 288f. See also Transposition of Hemodynamic mechanism, of neurogenic
in congenital diaphragmatic hernia great arteries (TGA) pulmonary edema development,
survivors, 225 Growth 495–496
laryngomalacia with, 245 abnormal, in congenital diaphragmatic Hemoptysis, and cystic fibrosis, 374
nocturnal asthma and, 317 hernia survivors, 225 Hemorrhage
postural drainage and, 361 slow, from inhaled corticosteroids, 331 intraparenchymal, 483, 483f
Gastrointestinal (GI) tract Grunting intraventricular, 187–193, 483, 483f.
decompression of in atelectasis, 167 See also Intraventricular
in gastroschisis management, 227 in respiratory distress syndrome, 72 hemorrhage (IVH)
in omphalocele management, 229 Guillain-Barré syndrome (GBS), 438–440 Heparin, nebulized, for lung injury in
necrotizing enterocolitis affecting, clinical manifestations of, 438–439 smoke inhalation, 464–465
199–204 course and prognosis of, 440 Heparin dilution, ABG sample errors
Gastroschisis, 226–228, 226f management and treatment of, 440 from, 11
GBS. See Guillain-Barré syndrome overview of, 435t Herbal therapies, for asthma, 336, 336b
(GBS) pathophysiology of, 438 Hereditary factors, in asthma, 314
Genetic factors, in asthma, 314 Gyri, development and purpose of, 37 Hernia, diaphragmatic, congenital,
Genetic testing, for cystic fibrosis, 359 214–226. See also Congenital
Gentle ventilation, in respiratory distress
syndrome, 95
H Herniation
diaphragmatic hernia (CDH)
Haemophilus influenzae type b (Hib),
Germinal matrix (GM) epiglottitis from, 417–418 of abdominal content, in congenital
in brain development, 36, 188 Hamartomas, nasal obstruction from, 242 diaphragmatic hernia, 214, 214f
hemorrhage in, ultrasound images of, Head brain, 486, 486f
189f circumference of, in determining fetal HFV. See High-frequency ventilation
Germinal matrix-intraventricular age, 33 (HFV)
hemorrhage (GM-IVH), 187. rotation of, position of endotracheal High-frequency chest wall oscillation
See also Intraventricular tube in trachea and, 5f (HFCWO), in cystic fibrosis
hemorrhage (IVH) Health history, as asthma risk factor, 310 management, 361, 363, 363f
Gestation, definition of, 32 Health policy ethics, 513 High-frequency ventilation (HFV)
Gestational age Healthcare team, supporting, in end-of-life in congenital diaphragmatic hernia
apnea in preterm infants and, 112 care, 53–540 management, 221
determining, 33 Hearing loss, sensorineural intraventricular hemorrhage and,
developmental progress and, 42t in congenital diaphragmatic hernia 192–193
lung development by, 70–71 survivors, 226 jet, 99–100
retinopathy of prematurity and, 204 from respiratory distress syndrome, for persistent pulmonary hypertension
Glasgow Coma Scale (GCS), 484, 485t 102 of newborn, 141, 142
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in pulmonary interstitial emphysema Hyperresponsiveness, airway, airflow in pulmonary interstitial emphysema, 171
prevention, 172–173, 172f, 172t limitation in asthma from, 311 rebound, from inhaled nitric oxide for
for neurogenic pulmonary edema, 497 Hypersensitivity response, type I, in persistent pulmonary
oscillatory (HFOV), 98–99 asthma, 311–312, 312f, 313b hypertension of newborn, 143
for acute respiratory distress Hypertension refractory, in acute respiratory distress
syndrome, 406–408, 407t persistent, complicating coarctation syndrome, monitoring for, 402
in patent ductus arteriosus repair, 272 in respiratory distress, oxygen therapy
management, 198 portal, in cystic fibrosis, 359 for, 79
for persistent pulmonary pulmonary. See Pulmonary Hypoxia, in congenital diaphragmatic
hypertension of newborn, hypertension (PHTN) hernia, 217
141–142 Hypertensive crisis, pulmonary, in Hypoxic gas delivery, during hypoplastic
for persistent pulmonary hypertension persistent pulmonary left heart syndrome repair, 295
of newborn, 141–142 hypertension of newborn, 144 Hypoxic-ischemic encephalopathy,
in pulmonary interstitial emphysema Hypertonic saline induced hypothermia of
prevention, 172–173 in bronchiolitis management, 389 newborn for, 50–51
for respiratory distress syndrome, in cystic fibrosis management, 370
97–100, 97f, 98f Hypertrophy, right ventricular, in atrial I
High-pressure positive expiratory septal defect, 265 Ibuprofen, intravenous, for patent ductus
pressure, in cystic fibrosis Hyperventilation arteriosus, 197
management, 367 for increased intracranial pressure, Immunizations, for tetanus, 443
Hirschsprung’s disease, meconium plug 486 Immunocompromised patients, epiglottitis
in, 152b intraventricular hemorrhage and, 191, in, 418
Histamine release, in type I 192–193 Immunoglobulin E (IgE) release, in type I
hypersensitivity response, 312, moderate, in cerebral perfusion pressure hypersensitivity response, 311,
312f, 313b management, 489 312f, 313b
HLHS. See Hypoplastic left heart in traumatic brain injury management, Immunoglobulin infusions, intravenous,
syndrome (HLHS) 489 for Guillain-Barré syndrome, 440
Hoarseness, in recurrent respiratory Hypocalcemia, respiratory distress in Immunotherapy, for asthma, 334
papillomatosis, 247 premature infants and, 74t Incubator, for oxygen delivery for
Home, as location of death, issues Hypocarbia, complicating high-frequency premature infants, 81t, 82
involving, 538–539, 538t ventilation, 97 Indomethacin, for patent ductus
Hospice agencies, 538 Hypoglycemia, respiratory distress in arteriosus, 197
Hospital, admitting infants/children to, premature infants and, 74t Induced hypothermia, of newborn, for
reasons for, 395b Hypoplasia hypoxic-ischemic
Hospital ethics committees, 513, 513f lung, from diaphragmatic hernia, 215 encephalopathy, 50–51
Huffs pulmonary, neonatal resuscitation and, Infant(s)
in active cycle breathing, 364 59 admitting to hospital, reasons for, 395b
in cystic fibrosis management, 363–364, Hypoplastic left heart syndrome (HLHS), as “belly breathers,” 5
364f 291–296, 291f full-term, disease of, 135–163
Human papillomavirus (HPV), clinical manifestations of, 291–292, growing, upsizing endotracheal tubes
recurrent respiratory 292f for, 89b
papillomatosis from, 247 course and prognosis of, 295–296 newborn. See Newborn
Hyaline membrane disease, 67. See also management and treatment of, 292–295, normal ABG values for, 11t
Respiratory distress syndrome 293f, 293t, 294b, 295b normal vital sign values for, 9t
(RDS) alternatives to three-stage repair in, as obligate nose breathers, 3, 386b
Hydrocarbons, chemical pneumonitis 294 pain assessment in, 7–8
from, 470–471 respiratory management during, premature. See Premature infant(s)
Hydroxocobalamin, for cyanide toxicity, 294–295, 295b research in, acceptable risk in, 506b
466 stage 1 of, 292–293, 293f, 293t social and language developmental
Hygiene hypothesis, for asthma, 314 stage 2 of, 293–294, 293f, 293t milestones for, 7
Hyperbaric chambers, for carbon stage 3 of, 293f, 293t, 294 with wheezing/asthma, influenza
monoxide poisoning, 466 pathophysiology of, 291 vaccinations for, 346b
Hypercapnia/hypercarbia Hypoplastic pulmonary veins, in total Infant botulism, 443
in bronchiolitis, 384 anomalous pulmonary venous Infection(s)
permissive return, 288 control of, in cystic fibrosis
in mechanical ventilation for asthma Hypotension, in pulmonary interstitial management, 372, 372t
exacerbation, 344 emphysema, 171 nasal obstruction from, 242
in near-drowning management, Hypothermia respiratory, viral
461–462, 462b induced, of newborn, for hypoxic- as asthma trigger, 316
in pulmonary interstitial emphysema, ischemic encephalopathy, 50–51 early, as asthma triggers, 315
171 moderate, in cerebral perfusion respiratory distress in premature
Hyperosmolar therapies, in cerebral pressure management, 489 infants and, 74t
perfusion pressure management, respiratory distress in premature spontaneous premature labor from, 67
489 infants and, 74t Infectious airway diseases, 415–431
Hyperoxia test Hypoxemia bacterial tracheitis as, 426–428. See
for cyanotic heart defects, 280 in apnea of prematurity, 114, 114f also Bacterial tracheitis
for persistent pulmonary hypertension in bronchiolitis, 383, 384 clinical features of, 417t
of newborn, 139 in congenital diaphragmatic hernia, 217 croup as, 422–426. See also Croup
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Inflammation
airway, in asthma, 311–312, 312f, 313b
Cushing’s triad and, 486
first-tier therapy for, 488–489
L
Labor
biomarkers of, in asthma diagnosis, second-tier therapy for, 489 definition of, 46
322 monitoring of, 485, 486f fetal monitoring during, 47
nasal obstruction from, 242 in traumatic brain injury, 485–486 preterm. See Preterm labor
spontaneous premature labor from, 67 Intraparenchymal hemorrhage, 483, 483f stages of, 46–47
Inflammatory cascade, 311–312, 312f Intrapartum fetal heart rate monitoring, 47 Lamellar body count, in fetal lung
down-regulating, fever in, 396b Intrapulmonary percussive ventilation maturity assessment, 41
Inflammatory mechanism, of neurogenic (IPV), in cystic fibrosis Language
pulmonary edema development, management, 367 critical, 176b
496 Intrapulmonary shunt, in respiratory developmental milestones in, 7
Influenza vaccinations, for infants with distress syndrome, 71 expressive, 6
wheezing/asthma, intramuscular Intrathoracic pressure, decreased, in receptive, 6
versus intranasal, 346b respiratory distress syndrome, 72 Laparotomy, exploratory, for necrotizing
Informed consent, in clinical ethics, Intraventricular hemorrhage (IVH), enterocolitis, 202–203
510–511 187–193, 483, 483f Laryngeal mask airway (LMA), sizes of,
Inhalation injuries, 462–467 clinical manifestations of, 188 by weight, 18t
burns and, 467 course and prognosis of, 193 Laryngoceles, airway obstruction from,
cyanide poisoning from, 466–467, 467b grading systems for, 187t 247
direct lung injury as, 463–465 incidence of, 187 Laryngomalacia, 245–246, 245b
systemic complications of, 465–466 management and treatment of, 190–193 Laryngopharyngeal reflux (LPR),
upper airway injury in, 462–463 preventive measures in, 190–191 laryngomalacia with, 245
Inhalation therapies, in cystic fibrosis ventilatory management in, 191–193 Laryngoscope
management, 368–371 pathophysiology of, 187–188 blade, sizes and types of, by weight, 16
bronchodilators, 368–369 therapist-driven ventilation protocols in upper airway foreign body removal,
inhaled antibiotics, 370 and, 192b 470
mucolytics, 369–370 ultrasound images of, 189f–190f Laryngospasm, in near-drowning, 455
optimal delivery of medications in, 371, Intubation Laryngotracheal reconstruction, for
371t in acute asthma exacerbation subglottic stenosis, 250
Inhaled antibiotics management, 343–344 Laryngotracheobronchitis, 422. See also
in cystic fibrosis management, 370 bronchial, for pulmonary interstitial Croup
in pneumonia management, 397, 398b, emphysema, 173, 173b bacterial, 426. See also Bacterial
398f in congenital diaphragmatic hernia tracheitis
Inhaled bronchodilators management, 219 Larynx, 245f
for bronchiolitis, 388–389 endotracheal opening of, in children vs. adults, 3, 4t
in pneumonia management, 397 for bacterial tracheitis, 427–428 recurrent respiratory papillomatosis of,
Inhaled medications, for croup, 424 for mechanical ventilation, 87–89 247–248, 247f, 248b
Inhaled steroids, in cystic fibrosis in neonatal resuscitation, 56, 56f supraglottic, epiglottitis and, 417
management, 370–371 premedication for, 88 Late decelerations, in fetal heart rate, 47,
Inlet ventricular septal defect, 266 procedure for, 88–89 49f
Inositol, for bronchopulmonary side effects of, 89 Latent phase of labor, 46
dysplasia, 125 in traumatic brain injury, 486–488, Law of Laplace, volume-control
Inotropes 487f, 488b ventilation and, 91
in congenital diaphragmatic hernia rapid sequence, 487–488, 488b Lecithin-sphingomyelin (L/S) ratio, in
management, 222 for upper airway injury, with inhalation fetal lung maturity assessment,
in Ebstein anomaly management, 298 injuries, 463 40
Insufflation-exsufflation devices Ipratropium bromide, for asthma, 335 Leffler formula, for weight assessment, 8
for Duchenne muscular dystrophy, Isoflurane, for status asthmaticus, 345b Length-for-weight percentiles
446, 446f IVH. See Intraventricular hemorrhage boys, birth to 36 months, 26f
to improve airway clearance, 437 (IVH) girls, birth to 36 months, 27f
Intensive care units (ICUs) Leukocytosis, in bacterial tracheitis, 427
acute asthma exacerbation
management in, 341–345
J Leukotrienes, release of, in type I
Jet ventilation, high-frequency, 99–100 hypersensitivity response, 312,
classifications of, 17–18, 18t–20t intraventricular hemorrhage and, 192 312f, 313b
epiglottitis management in, 421 for persistent pulmonary hypertension Levalbuterol
Intestine(s) of newborn, 141, 142 for acute asthma exacerbation, 339
malrotation of, with congenital in pulmonary interstitial emphysema for asthma, 335
diaphragmatic hernia, 216 prevention, 172–173, 172f, 172t in cystic fibrosis management, 368–369,
necrosis of, with gastroschisis Justice, as bioethical principle, 505f, 506 369t
following delivery, 227 Juvenile myasthenia gravis, 441, 442 Life support, extracorporeal, 145–150.
perforation of, with gastroschisis See also Extracorporeal
following delivery, 227
Intracranial pressure (ICP) K membrane oxygenation
(ECMO)
autoregulation of, 486, 487f Ketamine, for sedation for intubation in
asthma exacerbation, 344 Ligation, surgical, for patent ductus
effects of intubation on, limiting, 488 arteriosus, 197–198, 198f
increased Ketotifen, for asthma, 334
Kinesthetic stimulation, in apnea of Limb-girdle muscular dystrophy
cerebral perfusion pressure (LGMD), 446b
management and, 488, 488t prematurity, 117
Lipoids, aspiration of, 71–472
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Listening, active, 528b Mainstem bronchus, in children vs. setting for, in high-frequency oscillatory
Liver, cirrhosis of, in cystic fibrosis, 359 adults, 4t, 5 ventilation, 98
Lockjaw, in tetanus, 442 Maladaptation, of pulmonary vasculature, for ARDS, 407
Long-acting beta agonists (LABAs), for persistent pulmonary for congenital diaphragmatic hernia,
asthma, 334–335 hypertension of newborn from, 221
Loop diuretics, for bronchopulmonary 138 for intraventricular hemorrhage, 192
dysplasia, 126 Maldevelopment, of pulmonary for persistent pulmonary
Lower extremity paralysis, complicating vasculature, persistent hypertension in newborn, 142
coarctation repair, 272 pulmonary hypertension of for respiratory distress syndrome,
Lung(s) newborn from, 138 98, 99
complications involving, 165–184. See Malformation, gastroschisis as, 226 Mean arterial blood pressure (MAP),
also Pulmonary complications Malrotation, intestinal, with congenital calculation of, 8–9
contusion of, respiratory system effects diaphragmatic hernia, 216 Mechanical ventilation (MV)
of, 483 Mandatory vaccination, as ethical for acute respiratory distress syndrome,
development of, by gestational age, dilemma, 509 402–408, 403t
70–71 Mandible, small, in Robin sequence, 242, from near-drowning, strategy for, 460
direct injury to, from smoke inhalation, 243 for apnea of prematurity, 116
463–465 “catch up” growth of, 243b in asthma exacerbation, strategies for,
edema of. See Pulmonary edema Mandibular advancement, in Robin 344–345
elastic recoil of, in children vs. adults, sequence management, 243 atelectrauma from, 167
4t, 6 Manipulation, for enhancing compliance, for botulism, 445
fetal 505b bronchopulmonary dysplasia from,
development of, 33–35, 33t Manual therapy, for asthma, 337 118, 121. See also
maturity of. See also Fetal lung MAS. See Meconium aspiration syndrome Bronchopulmonary dysplasia
maturity (FLM) (MAS) (BPD)
assessing, 39–41 Mask(s) strategies related to, 123–124, 124f
hypoplasia of face, for oxygen delivery for premature for congenital diaphragmatic hernia
from diaphragmatic hernia, 215 infants, 81t, 82 conventional, 220–221
in respiratory distress syndrome, for oxygen delivery, 387t high-frequency, 221
70–71 Mask ventilation, in neonatal conventional, 89–96
injury to resuscitation, 54–56, 55f assist-control, 93, 94f
acute, acute respiratory distress Mast cell stabilizers, for breath-delivery ventilator types for,
syndrome and, 399 bronchopulmonary dysplasia, 90, 90f
from aspiration, 467 125 failing, 96
iatrogenic, minimization of, in Mast cells, in type I hypersensitivity flow rate for, 92–93
congenital diaphragmatic response, 312, 312f, 313b mode of, 93–94, 94f
hernia management, 220 Maternal stress, spontaneous premature oxygenation and, 94
involvement of, pediatric accidents labor from, 67 patient-triggered, 90
with, 453–480. See also Maximal expiratory pressure (MEP) pressure control, 90–91, 91t
Pediatric accidents, with in respiratory management of spinal pressure in, 94–95
pulmonary involvement cord injury, 494 pressure-regulated volume control, 92
microvascular maturation of, 6 in respiratory muscle strength pressure support, 94, 94f
overcirculation in, complications of, assessment, 436 respiratory rate in, 94–95
195–196 spirometry values for, 436t synchronized intermittent
transplantation of, in cystic fibrosis, Maximal inspiratory pressure (MIP) mandatory, 93–94, 94f
375 in respiratory management of spinal time-cycled, pressure limited, 90, 90f
Lung function, in asthma, 347 cord injury, 494 ventilator settings for, selecting, 92,
Lung profile test, in fetal lung maturity in respiratory muscle strength 95t
assessment, 40 assessment, 436 volume-assured pressure support, 92
Lung volume(s), 436f spirometry values for, 436t volume-control, 91–92
decreased, in sleep, nocturnal asthma Mean airway pressure (Paw) volume guarantee, 92
and, 316 calculation of, 217 volume in, 94, 95–96
spirometry values for, 436t in calculation of oxygen index, 139, 217 volume-targeted/adaptive, 92
Lymphangioma, microcystic, 244 control over, pressure control modes weaning from, 96
Lymphocytes providing, 404 discontinuing, 533–534
in inflammatory pathway of asthma, excessive/inadequate, complicating during gastroschisis reduction, 227
312, 312f, 313b high-frequency ventilation, 97 during hypoplastic left heart syndrome
T-cell. See T cells in high-frequency jet ventilation for repair, management of, 295
pulmonary interstitial for Guillain-Barré syndrome, 440
M emphysema, 172 management of, in atelectasis
Macroglossia, 244 in monitoring mechanical ventilation, prevention, 169
Macrophages, in type I hypersensitivity 87 for meconium aspiration syndrome,
response, 311, 312f, 313b for ARDS, 404 155–156, 156t
Magnesium in oxygenation management during in necrotizing enterocolitis
for acute asthma exacerbation, high-frequency ventilation, 142 management, 203
340–341 in respiratory management of for persistent pulmonary hypertension
oral, in asthma management, 342b necrotizing enterocolitis, of newborn, 140–141
Mai-Men-Dong-Tang, for asthma, 336b 203–204 in pneumonia management, 398, 399t
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576 Index
pneumopericardium complicating, 177 Methicillin-resistant Staphylococcus high-flow, for oxygen delivery, 387t.
pulmonary interstitial emphysema aureus (MRSA), bacterial See also High-flow nasal
complicating, 170 tracheitis and, 428 cannula, for oxygen delivery
high-frequency, 97–100, 97f, 98f Methylxanthines, for apnea of for oxygen delivery, 387t
for respiratory distress syndrome, prematurity, 115–116 for premature infants, 81, 81t
86–100 Microcystic lymphangioma, 244 description of, 169t
goals of, 87 Micrognathia, in Robin sequence, 242 Nasal continuous positive airway
intubation for, 87–89 Mid-arm circumference, in weight pressure (NCPAP)
side effects of, 87b assessment, 9b for apnea of prematurity, 116
in tetanus, 443 Midbrain, formation of, 36 in atelectasis prevention, 169–170, 169t
in traumatic brain injury management, Miller-Fisher syndrome, 438 bubble, 84–85, 84f
strategies for, 489–490 Minors, emancipated, medical decision- in resource-limited environments, 85b
Meconium making and, 506b complications of, 85
aspiration of, 57–58, 57b. See also Mixed apnea of prematurity, 113 components of, 83–84, 84f
Meconium aspiration syndrome Mold, as asthma trigger, 315 delivery methods for, 85t
(MAS) Molecular diffusion, in high-frequency guidelines for, 83b
definition of, 151 oscillatory ventilation, 407 indications for, 83
failure to pass, causes of, 152b Mometasone furoate (Asmanex for respiratory distress syndrome, 83–84
Meconium aspiration syndrome (MAS), Twisthaler), for asthma, 332t variable-flow, 84
151–157 Monro-Kellie doctrine, 485 ventilator, 84
clinical manifestations of, 152–153, Moral distress, in clinical ethics, 512 Nasal endoscopy, in choanal atresia
153b, 153f Morbidity, definition of, 32 evaluation, 240
course and prognosis of, 156–157 MRSA. See Methicillin-resistant Nasal passages, abnormalities of, 239–242
definition of, 151 Staphylococcus aureus (MRSA) adenoid hypertrophy as, 242, 242f
laboratory evaluation in, 153 Mucociliary clearance techniques, 437, 437t choanal atresia as, 239–241, 240f, 241f
management and treatment of, 153–156 Mucolytics, in cystic fibrosis management, choanal stenosis and, 241
cardiovascular support in, 156 369–370 with cleft lip, 241, 241f
delivery room interventions in, Mucopurulent exudates, in bacterial foreign bodies as, 241–242
153–155, 154b, 154f tracheitis, 426 hamartomas as, 242
extracorporeal membrane Mucus from infection/inflammatory
oxygenation in, 156 clearance of conditions, 242
mechanical ventilation in, 155–156, for bronchiolitis, 386 nasal polyps as, 242
156t in pneumonia management, 397–398 pyriform aperture stenosis as, 241
neonatal, 155–156 production of, increased vestibular stenosis as, 241
oxygen therapy in, 155 in asthma, 312 Nasal polyps, 242
parental support in, 156b in bronchiolitis, 383 Nasal stents, in choanal atresia repair,
pulmonary vasodilators in, 156 Multidisciplinary rehabilitation teams, 240
surfactant-replacement therapy in, 156 445b Nasopharynx, abnormalities of, 242
pathophysiology of, 151–152, 152f Multisystem organ failure, in severe adenoid hypertrophy as, 242, 242f
persistent pulmonary hypertension of burns, 467 Near-drowning, 454–462
newborn associated with, 139 Murmur, cardiac, auscultation of, 263, acute respiratory distress syndrome
risk factors for, 151 263t from, 456, 457f
Meconium aspirator, 154, 154f Murray Lung Injury Score, 401, 401t aspiration pneumonia from, 456
Meconium ileus, 152b Muscle relaxants, for intubation, 88 atelectasis in, 456
in cystic fibrosis, 357 Muscular dystrophy, overview of, 435t clinical manifestations of, 457
Meconium plug, 152b Muscular ventricular septal defect, 266, course and prognosis of, 461–462
Mediation, between treatment teams, 266f death or poor neurological outcomes
467b MV. See Mechanical ventilation (MV) in, variables associated with,
Medical confidentiality, in clinical ethics, Myasthenia gravis (MG), 441–442 462t
510 overview of, 435t definition of, 455
Medical errors, ethical duty to prevent, Myelin, 438b, 439f management and treatment of, 458–461
507–509 Myelomeningocele, neonatal negative pressure pulmonary edema in,
Medication errors, 14–15 resuscitation and, 59 455
Medulla, formation of, 36 Myocardial cells, in cardiac development, pathophysiology of, 455–456
Mesenchyme, lung development from, 34 35 secondary drowning and, 455–456
Mesentery, 216 Myocardial ischemia, from aortic surfactant dysfunction in, 456
Mesoderm, lung development from, 34 stenosis, 269 Nebulized medications, for dyspnea after
Metabolism, ABG sample errors from, 12 terminal extubation, 536–537
Metaproterenol, for asthma, 335 N Nebulizers, for inhalation medication
Methacholine, in bronchoprovocation Narcotics, for dyspnea after terminal delivery, in cystic fibrosis
testing, 321 extubation, 536 management, 371, 371t
Methemoglobin (MetHb) rule of double effect and, 518–519 NEC. See Necrotizing enterocolitis
for cyanide toxicity, 466 Nasal airway, sizes of, by weight, 18t (NEC)
monitoring of, in inhaled nitric oxide Nasal cannula Neck radiography
therapy, 143 in apnea of prematurity management, in croup, 423, 424f
Methemoglobinemia, from inhaled nitric 116 in epiglottitis, 419, 419f
oxide for persistent pulmonary FIO2 levels delivered to neonatal Necrosis, bowel, with gastroschisis
hypertension of newborn, 143 airway via, 81t following delivery, 227
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Necrotizing enterocolitis (NEC), Neurological accidents, 481–501 total anomalous pulmonary venous
199–204 neurogenic pulmonary edema and, return and, 287–288
clinical manifestations of, 200–201, 495–497 Nitrogen dioxide, as asthma trigger,
201f, 202t spinal cord injury as, 492–495. See also 316
course and prognosis of, 204 Spinal cord injury (SCI) Nitrogen washout
incidence of, 199 traumatic brain injury as, 482–491. See for pneumothorax, 175
management and treatment of, 202–204 also Traumatic brain injury prevention of, oxygen therapy in, 402
respiratory, 203–204 (TBI) Nocturnal asthma, mechanisms of,
surgical, 202–203 Neurological support, in extracorporeal 315–317
modified Bell’s staging criteria for, membrane oxygenation, 150 Nodules, vocal fold, 248–249
202t Neuromuscular blockade, in cerebral Non-rebreather mask, for oxygen
pathophysiology of, 199–200 perfusion pressure management, delivery, 387t
Nedocromil, for asthma, 333 489 Non–heart-beating organ donation
Needle decompression, of pneumothorax, Neuromuscular disorders, 433–452 (NHBOD), ethical issues
175 botulism as, 443–445 involving, 519–520
Negative pressure pulmonary edema, in Guillain-Barré syndrome as, 438–440. Noninvasive positive-pressure ventilation
near-drowning, 455, 455f See also Guillain-Barré (NIPPV)
Neonatal apnea. See also Apnea of syndrome (GBS) for acute asthma exacerbation, 342
prematurity (AOP) muscular dystrophies as, 445–447 for acute respiratory distress
causes of, 112b myasthenia gravis as, 441–442 syndrome, 403
Neonatal Infant Pain Scale (NIPS), 7 overview of, 435t for apnea of prematurity, 116
Neonatal intensive care units (NICUs), tetanus as, 442–443 in atelectasis prevention, 169
classifications of, 18t–19t Neurons, basics of, 438b, 439f in bronchiolitis management, 391
Neonatal myasthenia gravis, 441 Neuropathy, in Guillain-Barré syndrome, delivery methods for, 85t
Neonatal resuscitation, 45–623 438 in near-drowning management, 458
anticipating, 48–49, 49b Neutrophils, in inflammatory pathway of in respiratory management of spinal
cardiovascular support in, 56–57, 57f asthma, 313b cord injury, 494
care after, 57 Newborn for spinal muscular atrophy, 448–449
case studies on, 60–61 clinical course of, implications of Nonmaleficence, as bioethical principle,
with congenital anomalies, 58–59 development on, 41 505f, 506
discontinuing, 59 normal ABG values for, 11t Nonvigorous baby, definition of, 154
equipment for, 50, 50b normal vital sign values for, 9t Normothermia, as goal of neonatal
establishing and managing airway and periodic breathing in, 113, 113b resuscitation, 50
breathing during, 54–56, 54t, persistent pulmonary hypertension of, Normoventilation
55f, 56f 136–151. See also Persistent in cerebral perfusion pressure
in extreme prematurity, ethical pulmonary hypertension of management, 488
implications of, 514–516, 515t newborn (PPHN) in traumatic brain injury management,
initial assessment and interventions in, pulmonary complications in, 165–184 489–490
51–52 spontaneously breathing, oxygen- Normoxemia, 221
preparation for, 50 delivery devices for, 80–82, 81t Norwood procedure, for hypoplastic left
primary versus secondary apnea in, transient tachypnea of, 157–159, 157b, heart syndrome, 292–293, 293f,
52–53, 53f 158f 293t
with severe congenital anomalies, ethical transition of, to extrauterine life, 47–60 Nose breathers, obligate, infants as, 3,
implications of, 514–56, 515t resuscitation during, 45–63. See also 386b
shared cognition in, 59b Neonatal resuscitation Nuremberg Code, on ethical conduct of
special considerations for, 57–60 Newborn screening, for cystic fibrosis, research on humans, 21–22
supplemental oxygen use in, 57–58, 359 Nutritional support, for botulism, 444
58f, 58t NIPPV. See Noninvasive positive-pressure
temperature regulation in, 50–51 ventilation (NIPPV) O
withholding, 59 Nissen fundoplication, for gastric Obstructive apnea of prematurity, 113
Neonatal Resuscitation Program (NRP), secretion aspiration, 475 Obstructive sleep apnea (OSA)
49–50 Nitric oxide (NO) nocturnal asthma and, 317
algorithm of, 53f exhaled, fractional, as biomarker of in Robin sequence, 243
Neonate. See Newborn airway inflammation, 322 Off-label use of medication, 14
Nerve conduction studies, in Guillain- inhaled (iNO) Omalizumab, for asthma, 334
Barré syndrome diagnosis, 439 for acute respiratory distress Omphalocele, 228–229, 228f
Neural system, development of, 36–37 syndrome, 408 Ophiopogon Combination, for asthma,
Neurocognitive dysfunction, in for acute respiratory distress 336b
bronchopulmonary dysplasia syndrome, from near-drowning, Ophthalmoplegia, in Guillain-Barré
subjects, 127–128 461 syndrome, 438
Neurodevelopmental disability, from for bronchopulmonary dysplasia, Opioid medications, for dyspnea after
respiratory distress syndrome, 125–126 terminal extubation, 536
101–102 in congenital diaphragmatic hernia rule of double effect and, 518–519
Neurodevelopmental outcome (NDO) management, 222 Opisthotonic posturing, in tetanus, 443
of congenital diaphragmatic hernia, for hydrocarbon aspiration, 471 Oral airway, sizes of, by weight, 18t
225–226 for inhalation injuries, 464 Oral cavity, abnormalities of, 242–244,
intraventricular hemorrhage and, 193 for persistent pulmonary hypertension 243f, 244f
Neurogenic pulmonary edema, 495–497 of newborn, 142–144, 143f Oral secretions, aspiration of, 472–474
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Organ donation for retinopathy of prematurity, 206 Patent ductus arteriosus (PDA), 193–199
after cardiac death, ethical issues for transient tachypnea of newborn, clinical manifestations of, 196–197
involving, 519–520 158 closure of, hypoplastic left heart
discontinuation of mechanical Oxygenation syndrome and, 292
ventilation and, 534 assessment of, blood gas monitoring with congenital diaphragmatic hernia,
Oropharynx, abnormalities of, 242–244, in, 10–12, 11t, 12b, 13t, 14b 215
243f, 244f extracorporeal membrane. See also course and prognosis of, 199
Oscillating positive expiratory pressure Extracorporeal membrane incidence of, 193–194
therapy oxygenation (ECMO), 145–150 management and treatment of, 197–198,
in cystic fibrosis management, 366–367, ventilator settings affecting, 94 198f
366f Oxygenation index (OI) pathophysiology of, 194–196, 194f
for mucociliary clearance, 437t in congenital diaphragmatic hernia, pulmonary edema in, 196
Oscillatory ventilation, high-frequency, 217 Patent foramen ovale (PFO), 264
98–99 in persistent pulmonary hypertension with congenital diaphragmatic hernia,
in patent ductus arteriosus of newborn, 139 215–216
management, 198 persistent pulmonary hypertension of Paternalism, in decision making, 517, 517b
intraventricular hemorrhage and, 192 newborn therapies based on, Patient assessment, 6–14
for persistent pulmonary hypertension 141t blood gas monitoring in, 10–12, 11t,
of newborn, 141–142 Oxygenators, ECMO, 148 12b, 13t, 14b
Ostium primum atrial septal defect, 264 Oxyhemoglobin dissociation curve, in communication and, 6
Ostium secundum atrial septal defect, bronchiolitis, oxygen therapy developmental milestones in social and
264 and, 386, 386f language skills and, 7
Ostomies, creation of, for necrotizing Oxyhood, for oxygen delivery, 387t pain assessment in, 7–8, 8f
enterocolitis, 203 pulse oximetry in, 10, 11b
Oxygen P vital signs in, 8–9, 9t–10t
consumption of, in respiratory distress Pain weight in, 8, 26f–29f
syndrome, 72 neonatal, minimizing, 100–101 Patient care, ethical principles guiding,
Oxygen flowmeters, helium oxygen ratio in respiratory distress syndrome, 504–506, 505f
correction factor for, 388t management of, 100–101, 101b Patient positioning
Oxygen hood, for oxygen delivery for Palivizumab, in bronchiolitis prevention, for acute respiratory distress
premature infants, 81t, 82 392 syndrome, from near-drowning,
Oxygen mask, sizes of, by weight, 18t Palliative care 461
Oxygen Saturation Index, in acute concurrent, 530 in apnea of prematurity management,
respiratory distress syndrome definition of, 527 117
diagnosis, 401, 402b early referral for, 530 in bronchiolitis management, 390
Oxygen saturation (SpO2) teams providing, members of, 527t in cerebral perfusion pressure
preductal and postductal, in persistent Pancreatic insufficiency, in cystic fibrosis, management, 488
pulmonary hypertension of 357 for gastric secretion aspiration, 475
newborn, 139, 139f Pandemics, professional ethics and, 509 for laryngomalacia, 246
values for, after delivery, goals for, 58t Papillomatosis, respiratory, recurrent, prone
Oxygen therapy 247–248, 247f, 248b in acute respiratory distress
for acute asthma exacerbation, 339 Paradoxical embolus, risk of, in atrial syndrome management, 409
for acute respiratory distress syndrome, septal defect, 265 for airway obstruction in Robin
402 Paradoxical split, of second heart sound sequence, 243
for bronchiolitis, 386–388, 386f in aortic stenosis, 269 for neurogenic pulmonary edema, 497
for bronchopulmonary dysplasia, 123 Parainfluenza viruses, croup from, 422 in upper airway foreign body
for croup, 424 Paralysis management, 469
delivery devices for, 387t in congenital diaphragmatic hernia for pulmonary interstitial emphysema,
for dyspnea after terminal extubation, management, 223 173
535 flaccid, in Guillain-Barré syndrome, 438 Patient-triggered ventilation, for
for epiglottitis, 420 lower extremity, complicating respiratory distress syndrome,
home, for bronchopulmonary dysplasia, coarctation repair, 272 90
127 vocal cord/fold, 248 Paw. See Mean airway pressure (Paw)
during hypoplastic left heart syndrome complicating coarctation repair, 272 PDA. See Patent ductus arteriosus (PDA)
repair, 294 Paresis, in Guillain-Barré syndrome, 438 Peak expiratory flow (PEF), monitoring
for meconium aspiration syndrome, Partial atrioventricular septal defects, of, in asthma management,
155 268 329–330, 329f
in neonatal resuscitation, 57–58, 58f, 58t Partial non-rebreather mask, for oxygen Peak expiratory flow rate (PEFR), in
in patent ductus arteriosus delivery, 387t respiratory management of
management, 198 Partial obstruction of airways, by spinal cord injury, 494
for persistent pulmonary hypertension meconium, 152 Peak inspiratory pressure (PIP)
of newborn, 140 Partial pressure of carbon dioxide in respiratory rate and, management
for pneumonia, 396 blood (PaCO2), assessment of, of, 94–95
for respiratory distress syndrome, 79–82 blood gas monitoring in, 10–12, selection of, 95
oxygen-delivery devices for 11t setting for, in high-frequency jet
spontaneously breathing Partial pressure of oxygen in blood ventilation, 99
neonates in, 80–82, 81t (PaO2), assessment of, blood Pediatric centers, adult-aged patients in,
titrating FIO2 during, 79–80 gas monitoring in, 10–12, 11t 529b
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Index 579
Pediatric intensive care units (PICUs), therapies for, based on oxygenation blood cultures in, 396
classifications of, 19t–20t index, 141t bronchoalveolar lavage in, 396
Pediatric Research Equity Act (PREA), from underdevelopment, 138 classification of, 393
14 Pet allergens, as asthma trigger, 315–316 clinical manifestations of, 394–396
PEEP. See Positive end-expiratory pH, arterial, assessment of, blood gas course and prognosis of, 398–399
pressure (PEEP) monitoring in, 10–12, 11t diagnostic testing for, 395–396
Pendelluft, in high-frequency oscillatory Phagocytosis, 313b management and treatment of, 396–398
ventilation, 407 Pharmaceuticals, maintenance, for fluid management in, 397
Pentamidine isethionate, inhaled, in Duchenne muscular dystrophy, glucocorticoids in, 398
pneumonia management, 397, 447 inhaled antibiotics in, 397, 398b,
398b, 398f Pharmacodynamic factors, definition of, 398f
Penumbra, in traumatic brain injury, 15 inhaled bronchodilators in, 397
489–490 Pharmacokinetic factors, definition of, 15 mechanical ventilation in, 398, 399t
PEP. See Positive expiratory pressure Pharmacological treatment of dyspnea oxygen therapy in, 396
(PEP) after terminal extubation, suctioning and mucus clearance in,
Percussion, in cystic fibrosis 535–536 397–398
management, 360–361 Pharmacology, 14–16 pathophysiology of, 394, 394f
Perforation, bowel, with gastroschisis Pharyngeal lymphoid tissue, in children Pneumocystis jiroveci, 397b
following delivery, 227 vs. adults, 3, 4t risk factors for, 393
Pericardiocentesis, for tamponade with Phenotypic symptoms, in asthma severity assessment for, 394t
pneumopericardium, 178 diagnosis, 310 signs and symptoms of, 394
Perimembranous ventricular septal Phosphatidylcholine (PC), in surfactants, sputum cultures in, 396
defect, 266, 266f 35 ventilator-associated, neurogenic
Periodic breathing, in neonates, 113, Phosphatidylglycerol (PG) pulmonary edema differentiated
113b in fetal lung maturity assessment, 40 from, 496, 496t
Peripheral chemoreceptors, in control of in surfactants, 35 viral
respiratory pattern, 113–114 Phospholipids, in surfactant, 69–70 chest radiograph of, 395f, 395t
Peritoneal drainage, for necrotizing PHTN. See Pulmonary hypertension organisms causing, 393, 395t
enterocolitis, 203 (PHTN) pharmacological therapy for, 395t
Peritonsillar abscess, 244 Physical exercise, for asthma, 338 Pneumonitis
Permissive hypercapnia Physical restraint, for enhancing aspiration, respiratory system effects
in mechanical ventilation for asthma compliance, 505b of, 483
exacerbation, 344 Physiological differences, between chemical, 470–472
in near-drowning management, children and adults, 3, 5–6 from meconium aspiration, 152
461–462, 462b Physiotherapy, chest. See Chest Pneumopericardium, 177–178, 178f
in prevention of bronchopulmonary physiotherapy (CPT) Pneumoperitoneum, complicating bowel
dysplasia, 123 PIE. See Pulmonary interstitial decompression, 202
in respiratory distress syndrome emphysema (PIE) Pneumothorax, 174–176
management, 95 Pierre-Robin syndrome, 242–244, 243f clinical manifestations of, 174–175
Persistent pulmonary hypertension of Pilocarpine iontophoresis, in cystic complicating cystic fibrosis, treatment
newborn (PPHN), 136–151 fibrosis diagnosis, 359 of, 374
changes to fetal circulation during, 138 PIP. See Peak inspiratory pressure (PIP) complicating meconium aspiration
classification of, 138 Placenta, delivery of, 46, 47 syndrome, 157
clinical manifestations of, 138–139 Plasma cells, in type I hypersensitivity course and prognosis of, 176
course and prognosis of, 151 response, 311, 312f definition of, 174
diagnoses associated with, 137b Plasmapheresis, for Guillain-Barré management and treatment of, 175
incidence of, 136–137 syndrome, 440 pathophysiology of, 174
in maladaptation, 138 Plateau pressure, in ventilation for acute respiratory system effects of, 483
from maldevelopment, 138 respiratory distress syndrome, risk factors for, 174
management and treatment of, 404 spontaneous, 174, 174b
140–150, 140b Pleural effusion, in pneumonia, 179 tension, 174–175, 176f
cardiac support in, 142 Pleurodesis, for pneumothorax in cystic Poiseuille’s law
extracorporeal membrane fibrosis, 374 in airway resistance calculation, 422
oxygenation in, 145–150. See Pneumatosis, in necrotizing enterocolitis, in endotracheal tube resistance
also Extracorporeal membrane 200–201, 201f calculation, 89
oxygenation (ECMO) Pneumocystic jiroveci pneumonia, 397b Poisoning, carbon monoxide, from
objectives of, 140 Pneumocytes, type I, injury to, in acute smoke inhalation, 465–466
oxygen therapy in, 140 respiratory distress syndrome, Polyhydramnios, in congenital
pulmonary vasodilators in, 142–144, 400 diaphragmatic hernia, 216
144b Pneumomediastinum, 176–177, 177f Polyps, nasal, 242
respiratory support in, 140–142 Pneumonia, 178–180, 393–399 Polyradiculoneuropathy, demyelination,
surfactant therapy in, 142 anti-infectives for, 396–397 in Guillain-Barré syndrome, 438
pathophysiology of, 137–138 aspiration. See Aspiration pneumonia Polysomnogram, in diagnosis of
in preterm infants, 137b bacterial obstructive sleep apnea in
pulmonary hypertensive crisis in, 144 antibiotics for, 396–397 Robin sequence, 243
respiratory alkalosis and, 140, 141b chest radiograph of, 395f, 395t Pons, formation of, 36
risk factors for, 137 organisms causing, 393, 395t Pores of Kohn, in alveoli, significance
sildenafil for, 144 pharmacological therapy for, 395t of, 6
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580 Index
Positioning, body. See Patient retinopathy of prematurity as, Preterm infants. See Premature infant(s)
positioning 204–207. See also Retinopathy Preterm labor
Positive end-expiratory pressure (PEEP) of prematurity (ROP) causes of, 66–67
increased, for neurogenic pulmonary normal ABG values for, 11t glucocorticoids during, 41
edema, 496–497 oxygen administration protocols for, risk factors for, 39b
intrinsic or auto-, assessment for, 345, 80b tocolytics during, 41
345f oxygen-delivery devices for, 81t Pributerol, for asthma, 335
in near-drowning management, 458–459 pain in, management of, 100–101, 101b Professional competency, duty to obtain,
with atelectasis, 459 persistent pulmonary hypertension of 507
oxygenation and, 94 newborn in, 137b Professional ethics, 506–509
in patent ductus arteriosus management, postdelivery risk factors for, 75b medical errors and, 507–509
198 pulmonary complications in, 165–184 pandemics and, 509
for preterm infant, 76 atelectasis as, 166–170. See also professional competency and, 507
setting for, in high-frequency jet Atelectasis public health emergencies and, 509
ventilation, 99 pneumomediastinum as, 176–177, unsafe staffing levels and, 508b
Positive expiratory pressure (PEP), 177f Proliferative stage, of acute respiratory
365–366, 365b pneumonia as, 178–180 distress syndrome, 400, 400t,
bubble/underwater, 365b pneumopericardium as, 177–178, 456
high-pressure, 367 178f Prone positioning
oscillating, 366–367, 366f pneumothorax as, 174–176, 174b, in acute respiratory distress syndrome
for mucociliary clearance, 437t 176f. See also Pneumothorax management, 409
Positive pressure, early initiation of, in pulmonary interstitial emphysema for airway obstruction in Robin
near-drowning management, as, 170–173. See also sequence, 243
458 Pulmonary interstitial Propofol, for sedation for intubation in
Positive-pressure ventilation (PPV) emphysema (PIE) asthma exacerbation, 344
for double aortic arch, 273 pulse oximetry level recommendations Propolis, for asthma, 336b
invasive, for apnea of prematurity, 116 based on age in minutes, 76t Prostacyclin, in congenital diaphragmatic
in neonatal resuscitation, 54–56 respiratory distress in, severity of, hernia management, 222b
endotracheal intubation for, 56, 56f factors increasing, 74t Prostaglandin E (PGE), for cyanosis in
noninvasive, 54–56, 54t–55t, 55f Prematurity neonate, 281
noninvasive, 86 apnea of, 112–118. See also Apnea of Prostaglandins
delivery methods for, 85t prematurity (AOP) for aortic stenosis, 269
for respiratory distress syndrome, categories of, 68b in fetal circulatory changes at delivery,
85t, 86 in congenital diaphragmatic hernia, 39
for preterm infant, 76 225b inhibitors of, for patent ductus
for spinal muscular atrophy, 448 extreme, 51b arteriosus, 197
Postcoarctectomy syndrome, 272 neonatal resuscitation in, ethical for pulmonic stenosis, 270–271
Postductal SpO2, in persistent pulmonary implications of, 514–516, 515t release of, in type I hypersensitivity
hypertension of newborn, 139, incidence of, 66 response, 312, 312f, 313b
139f multisystem effects of, 186–187 Pseudoglandular phase, of fetal lung
Postural drainage, 360, 361, 362f retinopathy of, 204–207. See also development, 33t, 34, 34f
PPHN. See Persistent pulmonary Retinopathy of prematurity Pseudohypertrophy, in limb-girdle
hypertension of newborn (ROP) muscular dystrophy, 445b
(PPHN) Prenatal care, as asthma risk factor, 309 Pseudomembranous croup, 426. See also
PPV. See Positive-pressure ventilation Prenatal findings, in congenital Bacterial tracheitis
(PPV) diaphragmatic hernia, 216 Pseudomonas aeruginosa, in cystic
Preadolescents, autonomy and, 505 Prenatal intervention, for hypoplastic left fibrosis, inhaled antibiotics for,
Preductal SpO2, in persistent pulmonary heart syndrome, 294 370
hypertension of newborn, 139, Preschool-age children Ptosis, in myasthenia gravis, 441
139f normal vital sign values for, 9t Public health emergencies, professional
Pregnancy, stages of development in, social and language developmental ethics and, 509
32–33 milestones for, 7 Pulmonary atresia, in Ebstein anomaly,
Premature infant(s) Presidential Commission for the Study of 297–298
care of, history of, 66 Bioethical Issues, 513 Pulmonary contusion, respiratory system
family-centered decision-making on, in Pressure control ventilation (PCV) effects of, 483
delivery room, 68b for acute respiratory distress syndrome, Pulmonary edema
growing, upsizing endotracheal tubes 404, 405f complicating bronchopulmonary
for, 89b description of, 90–91 dysplasia, treatment of, 126
multisystem complications in, 185–212 during hypoplastic left heart syndrome in near-drowning, clinical
intraventricular hemorrhage as, repair, 295 manifestations of, 457
187–193. See also Intraventricular for respiratory distress syndrome, negative pressure, in near-drowning,
hemorrhage (IVH) 90–91, 91t 455, 455f
necrotizing enterocolitis as, 199–204. Pressure support ventilation, 94, 94f neurogenic, 495–497
See also Necrotizing Preterm birth(s) in patent ductus arteriosus, 196
enterocolitis (NEC) definition of, 32 respiratory system effects of, 484
patent ductus arteriosus as, 193–199. with omphalocele, 228 Pulmonary exacerbations, in cystic
See also Patent ductus prevention of, in respiratory distress fibrosis, therapy for, 373–374,
arteriosus (PDA) syndrome prevention, 73–74 373b
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Index 581
Pulmonary function, in measuring preductal and postductal Respiratory distress
bronchopulmonary dysplasia saturations, 139f assessment instrument for, 384t
subjects, 127 in monitoring mechanical ventilation in croup, 423, 423t
Pulmonary function testing (PFT) for ARDS, 403 in epiglottitis, recognizing, 420
in asthma diagnosis, 320 for pneumonia, 398 in near-drowning, clinical
in respiratory management of spinal in patient assessment, 10, 11b manifestations of, 457
cord injury, 493 in respiratory management of spinal severity of, in premature infants,
Pulmonary hypertension (PHTN) cord injury, 493 factors increasing, 74t
in atrial septal defect, 265 Pulse pressure signs of, in meconium aspiration
in congenital diaphragmatic hernia, in aortic stenosis, 269 syndrome, 152, 153b
217 widened, in patent ductus arteriosus, Respiratory distress syndrome (RDS),
inhaled nitric oxide for, 222 196 65–109
persistent, of newborn, 136–151. See Pulsus paradoxus, in asthma acute, 399–409. See also Acute
also Persistent pulmonary exacerbations, 326 respiratory distress syndrome
hypertension of newborn Pulsus parvus et tardus, in aortic stenosis, (ARDS)
(PPHN) 269 characteristics of, 68f
Pulmonary hypertensive crisis, in persistent Pycnogenol, for asthma, 336b chest wall overcompliance in, 71
pulmonary hypertension of Pyriform aperture stenosis, 241 clinical manifestations of, 72, 73f, 74f
newborn, 144 course and prognosis of, 101–102
Pulmonary hypoplasia, neonatal
resuscitation and, 59
Q dead space ventilation in, 71
incidence of, 67–69
Qp/Qs measurement, in atrial septal
Pulmonary interstitial emphysema (PIE), intrapulmonary shunt in, 71
defect, 265
170–173 intrathoracic pressure decrease in, 72
Quinsy, 244
clinical manifestations of, 171, 171f lung hypoplasia in, 70–71
course and prognosis of, 173 management and treatment of, 72–101
definition of, 170 R corticosteroids in, 75
management and treatment of, 171–173, Race, as asthma risk factor, 309 in delivery room, 75–76, 75b, 76b
172t, 1721f Radiography mechanical ventilation in, 86–100.
pathophysiology of, 170–171, 170f chest. See Chest radiography (CXR) See also Mechanical ventilation
Pulmonary trunk, development of, 36, 36f neck (MV), for respiratory distress
Pulmonary valve regurgitation, treatment in croup, 423, 424f syndrome
for, 285, 285b in epiglottitis, 419, 419f oxygen therapy in, 79–82. See also
Pulmonary vascular resistance (PVR) Rapid sequence intubation (RSI), 487–488, Oxygen therapy, for respiratory
closure of patent ductus arteriosus and, 488b distress syndrome
194–195 Rashkind procedure, for transposition of pain management in, 100–101, 101b
in hypoplastic left heart syndrome great arteries, 290, 290f surfactant replacement therapy in,
(HLHS), 291 RDS. See Respiratory distress syndrome 77–79, 77b, 78t, 79f. See also
Pulmonary vasculature (RDS) Surfactant replacement therapy,
maladaptation of, persistent pulmonary Receptive language, 6 for preterm infant
hypertension of newborn from, Recovery phase, of acute respiratory management of, noninvasive
138 distress syndrome, 456 respiratory support in, 82–86
maldevelopment of, persistent Recurrent respiratory papillomatosis oxygen consumption in, 72
pulmonary hypertension of (RRP), 247–248, 247f, 248b pathophysiology of, 69–72
newborn from, 138 Refractory hypoxemia, in acute prevention of, 73–74
underdevelopment of, persistent respiratory distress syndrome, pulmonary interstitial emphysema
pulmonary hypertension of monitoring for, 402 complicating, 170
newborn from, 138 Refusal, conscientious, in clinical ethics, risk factors for, 69b
Pulmonary vasodilators 512 Silverman-Andersen Scoring System
for congenital diaphragmatic hernia, Regurgitation, tricuspid, in Ebstein and, 72, 73f
221–222, 222b anomaly, 296, 297 spontaneous pneumomediastinum
for meconium aspiration syndrome, 156 Rehabilitation teams, multidisciplinary, complicating, 176
for persistent pulmonary hypertension 445b surfactant deficiency in, 69–70, 70b,
of newborn, 142–144, 144b Research 70f
Pulmonary vein confluence, 285 ethical principles guiding, 504–506, thoracic mechanics and work of
Pulmonic stenosis, 270–271, 270f 505f breathing in, 71
cardiac auscultation in, 263t on humans, ethics and, 21–22 Respiratory function, circadian
Pulmozyme. See DNase; Dornase alfa in infants and children, acceptable risk modulation of, nocturnal
(rhDNase, Pulmozyme) in, 506b asthma and, 316
Pulse oximetry Resection, of bowel after delivery with Respiratory illness, acute, in Duchenne
in acute asthma exacerbation gastroschisis, 227 muscular dystrophy, 447
assessment, 339 Residual volume, spirometry values for, Respiratory management during
in bronchiolitis assessment, 385, 386 436t hypoplastic left heart syndrome
in ECMO support, 148 Respiration repair, 294–295
home, in spinal muscular atrophy type definition of, 71 Respiratory muscle training, in spinal
II, 449 ventilation differentiated from, 71 cord injury management, 494
levels by, recommended, for preterm Respiratory alkalosis, persistent Respiratory patterns, in traumatic brain
infants based on age in minutes, pulmonary hypertension of injury, 484, 484f
76t newborn and, 140, 141b Respiratory rate
2831_Index_563-588 28/03/14 3:30 PM Page 582
582 Index
inspiration time and, in mechanical Saline, hypertonic for acute asthma exacerbation, 339–340
ventilation, 95 in bronchiolitis management, 389 for exercise-induced asthma, 331b
peak inspiratory pressure and, in in cystic fibrosis management, 370 ventilation-perfusion mismatch and,
mechanical ventilation, Saltatory syndrome, in intraventricular 335b
management of, 94–95 hemorrhage, 188 Shunt, intrapulmonary, in respiratory
Respiratory syncytial virus (RSV) Sano modification, in hypoplastic left distress syndrome, 71
bronchiolitis from, 383 heart syndrome management, Sildenafil
testing for, 384 293 in congenital diaphragmatic hernia
transmission of, 383 Scaphoid abdomen, in congenital management, 222b
Restraint, physical, for enhancing diaphragmatic hernia, 216, 216f for persistent pulmonary hypertension
compliance, 505b Scapulae, winged, in limb-girdle muscular of newborn, 144
Reticulogranular pattern, on chest dystrophy, 445b Silent aspiration, 473
radiograph in respiratory School-age child(ren) Silverman-Andersen Scoring System, for
distress syndrome, 72, 74f normal vital sign values for, 9t–10t respiratory distress
Retina, prenatal development of, 204–205 pain assessment in, 8 quantification, 72, 73f
Retinal vascularization pattern diagram, SCI. See Spinal cord injury (SCI) Sinus disease, in cystic fibrosis, 359
205f Scoliosis, development of, in Sinus venosus type atrial septal defect,
Retinol, for bronchopulmonary dysplasia, neuromuscular disease, 437 264
125 Screening, newborn, for cystic fibrosis, 359 Sinusoidal fetal heart rate pattern, 47, 48f
Retinopathy of prematurity (ROP) Secretions Skeletal deformities, in limb-girdle
clinical manifestations of, 205–206 at end of life, managing, 537 muscular dystrophy, 445b
course and prognosis of, 207 oral, aspiration of, 472–474 Skin stimulation, for apnea of
diagnosis of, in rural ICU, telemedicine Sedation prematurity, 117
in, 206b in cerebral perfusion pressure Sleep-related disordered breathing, in
incidence of, 204 management, 488 Duchenne muscular dystrophy,
management and treatment of, 206–207 for intubation, in asthma exacerbation, 447
oxygen therapy for, 206 343–344 Sleep-related environmental factors, in
pathophysiology of, 204–205 for mechanical ventilation, for nocturnal asthma, 317
progression of, 207f persistent pulmonary Sleep studies, in respiratory management
screening for, 205, 205f hypertension of newborn, of spinal cord injury, 494
stages of, 205b 140–141 SLS. See Spring-loaded silo (SLS)
surgical treatments for, 206–207 terminal, 537 Smoke inhalation
Retropharyngeal abscess, 244 See-saw breathing pattern, in respiratory direct lung injury from, 463–465
Rib(s) distress syndrome, 72 systemic complications of, 465–466
in children vs. adults, 5 Seldinger technique, 255 Smooth muscle, airway, unloading of,
fracture of, respiratory system effects Self-inflating bag, for positive-pressure nocturnal asthma and, 316
of, 484 ventilation, 54–55, 54t Sniffing position, for opening airway, 5,
Ribavirin (Virazole), in bronchiolitis Sellick’s maneuver, 487, 487f 6f
management, 390–391 in children, 6 Social developmental milestones, 7
Right ventricular hypertrophy, in Sensorineural hearing loss Socioeconomic status, as asthma risk
tetralogy of Fallot, 282 in congenital diaphragmatic hernia factor, 310
Right ventricular outflow tract survivors, 226 Sodium thiosulfate, for cyanide toxicity,
obstruction (RVOTO) from respiratory distress syndrome, 466
recurrent, after tetralogy of Fallot 102 Soma, 438b, 439f
repair, 284 Sepsis, respiratory distress in premature Spasmodic croup, 423b
in tetralogy of Fallot, 282–283 infants and, 74t Spinal cord injury (SCI), 492–495
Risus sardonicus, in tetanus, 442, 442f Septa, in alveolar saccules, 35, 35f clinical manifestations of, 492–493
Robin sequence, 242–244, 243f Septal wall defects, 263–268 course and prognosis of, 495
ROP. See Retinopathy of prematurity atrial septal defect as, 263–266. See management and treatment of, 493–495
(ROP) also Atrial septal defect (ASD) pathophysiology of, 492
Rule of double effect, 518–519 atrioventricular septal defect as, 267–268 Spinal muscular atrophy (SMA), 447–449,
in end-of-life care, 536 ventricular septal defect as, 266–267. 448f, 448t
Rule of nines, in calculating percentage See also Ventricular septal overview of, 435t
of skin burned, 467 defect (VSD) type 1, medical care for, ethical
RVOTO. See Right ventricular outflow Septostomy, atrial, for transposition of complexity of, 516–518
tract obstruction (RVOTO) great arteries, 290, 290f types of, 516t
Septum, definition of, 263 Spine, cervical, 492f
S Septum primum, 264 injuries to, 492–493
SABAs. See Short-acting beta agonists Septum secundum, 264 injury to, from intubation, minimizing,
(SABAs) Serosanguineous fluids, in airway in near- 487
Saccular cysts, airway obstruction from, drowning, 457 Spirometry
247 Shake test, in fetal lung maturity in asthma diagnosis, 320
Saccular phase, of fetal lung development, assessment, 40 in evaluation of lung volumes and
33t, 35, 35f Shaken baby syndrome, 491b ventilation, 436, 436t
Saccules, alveolar, 35, 35f Shared cognition, in neonatal Spontaneous pneumomediastinum,
Sacs, alveolar, 35, 35f resuscitation, 59b 176–177
Salbutamol, for bronchopulmonary Shock, in necrotizing enterocolitis, 200 Spontaneous pneumothorax, 174, 174b
dysplasia, 126 Short-acting beta agonists (SABAs) Spring-loaded silo (SLS)
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Index 583
in staged closure of gastroschisis,
227–228, 228f
Supraglottitis, 417. See also Epiglottitis
Supraglottoplasty, for laryngomalacia,
T
T cells, in type I hypersensitivity
in staged closure of omphalocele, 229 246 response, 311, 312f, 313b
Sputum cultures, in pneumonia diagnosis, Supravalvar stenosis, after transposition T-piece resuscitator, for positive-pressure
396 of great arteries correction, ventilation, 55, 55t
Sputum eosinophils, as biomarkers of 290–291 Tachycardia
airway inflammation, 322 Supraventricular tachycardia, in Ebstein definition of, 47
Staffing levels, unsafe, 508b anomaly, 297 supraventricular, in Ebstein anomaly,
Starling’s forces, lung fluid clearance management of, 298 297
during delivery and, 157 Surfactant management of, 298
Static compliance, calculation of, 404 chemical composition of, 35, 69–70, 70f Tachypnea
Stature-for-age percentiles deficiency of, 35 in atelectasis, 168
boys, 2 to 20 years, 28f in respiratory distress syndrome, of newborn, transient, 157–159, 157b,
girls, 2 to 20 years, 29f 69–70 158f
Status asthmaticus, 327t, 328, 338 dysfunction of, in near-drowning, 456 in traumatic brain injury, 484, 484f
intubation for, 343b exogenous. See also Surfactant Tactile stimulation, for apnea of
isoflurane for, 345b replacement therapy prematurity, 117
magnesium for, 340 for atelectasis, in near-drowning, 459 Tamponade, in pneumopericardium, 178
terbutaline for, 340 for hydrocarbon aspiration, 471 TAPVR. See Total anomalous
Steam, inhalation injuries from, 462 types of, 77 pulmonary venous return
Stenosis function of (TAPVR)
aortic, 268–270, 268f agents inhibiting, 70, 70b Target effect, in inhaled medication
choanal, 241 loss of, in acute respiratory distress dosage determination, 15
pulmonic, 270–271, 270f syndrome, 400 Taylor dispersion, in high-frequency
pyriform aperture, 241 Surfactant-albumin (S/A) ratio, in fetal oscillatory ventilation, 407
subglottic, 249–251 lung maturity assessment, 40 TBI. See Traumatic brain injury (TBI)
vestibular, 241 Surfactant replacement therapy. See also TDx Fetal Lung Maturity test, 40
Stents, nasal, in choanal atresia repair, Surfactant, exogenous Team, healthcare, supporting, in end-of-
240 for acute respiratory distress syndrome, life care, 539–540
Steroids, inhaled, in cystic fibrosis 408 Telemedicine, in retinopathy of
management, 370–371 for meconium aspiration syndrome, prematurity diagnosis in rural
Stimulation, in apnea of prematurity 156 ICU, 206b
management, 117 for preterm infant, 77–79, 77b, 78t, 79f Temperature
Stress, spontaneous premature labor for bronchopulmonary dysplasia, 123 ABG sample errors from, 12
from, 67 complications of, 79 delivery room, for preterm birth, 75–76
Stretching, spontaneous premature labor in delivery room, 76, 77b instability of, respiratory distress in
from, 67 dosage for, 78t premature infants and, 74t
Stridor equipment and technique for, 78–79 regulation of, in neonatal resuscitation,
in laryngomalacia, 245 for persistent pulmonary 50–51
in subglottic stenosis, 249 hypertension of newborn, 142 Tension pneumothorax, 174–175, 176f
Subarterial ventricular septal defect, 266 positive response to, 79, 79f Terminal extubation, 518
Subdural hematoma, 483, 483f prophylactic, 77 terminal weaning versus, 533–534
Subglottic airway, epiglottitis and, 417 rescue, 77 Terminal sedation, 537
Subglottic stenosis, 249–251 for preterm infants, volutrauma from, Tet spell, in tetralogy of Fallot, 283
Subglottis prevention of, 168 Tetanus, 442–443
abnormalities of, 249–251 for acute respiratory distress syndrome, overview of, 435t
cysts of, 251 from near-drowning, 461, 461b Tetralogy of Fallot (TOF), 282–285, 282f
hemangioma of, 251 in congenital diaphragmatic hernia clinical manifestations of, 283, 283f
Suctioning, in pneumonia management, management, 221 course and prognosis of, 285
397–398 for pulmonary edema from patent in developing countries, 283b
Sudden infant death syndrome (SIDS), ductus arteriosus, 198 management and treatment of, 284–285,
risk and prevention factors for, Surgical ligation, for patent ductus 284b
390b arteriosus, 197–198, 198f pathophysiology of, 282–283
Sulci, development and purpose of, 37 Swallowing, dysfunctional, in aspiration repair of
Sulfites, asthma exacerbations from, 337 of oral secretions, 472 early, 284
Supracristal ventricular septal defect, Sweat test, for cystic fibrosis, 359 versus staged repair, 284b
266 Synapse, 438b, 439f late complications of, 284–285
Supraglottic larynx, epiglottitis and, Synchronized ventilation variations of, 282b
417 intermittent mandatory, for respiratory Theophylline, for asthma, 333–334
Supraglottis distress syndrome, 93–94, 94f Therapist-driven protocols, 489b
abnormalities of, 244–247 for persistent pulmonary hypertension Thermal injuries, to lung from smoke
ectopic thyroid tissue as, 246–247 of newborn, 140 inhalation, 463–465
epiglottitis as, 246 Systemic vascular resistance, increase in, Theron formula, for weight assessment, 8
laryngoceles as, 247 during transition to extrauterine Thiazide diuretics, for bronchopulmonary
laryngomalacia as, 245–246 life, 48 dysplasia, 126
saccular cysts as, 247 Systemic vascular resistance (SVR), in Thoracic cage, in children vs. adults, 4t, 5
vallecular cysts as, 246, 246f hypoplastic left heart syndrome Thoracic expansion breaths, in active
location of, 244, 245f (HLHS), 291 cycle breathing, 364
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584 Index
Thoracostomy drainage, of pneumothorax, Tracheoesophageal fistula (TEF), 251–253, Trisomy 21 (Down syndrome)
175 252f nasal obstruction in, 241
Thorax, mechanics of, work of breathing Tracheomalacia, 252 omphalocele and, 228
and, in respiratory distress Tracheostomy Truncus arteriosus, 298–300, 298f
syndrome, 71 for adults and children, indications for, in fetal cardiac development, 36, 36f
Thymectomy, for myasthenia gravis, 442 254b Tylophora indica, for asthma, 336b
Thyroid tissue, ectopic, 246–247 definition of, 254 Type I cells, formation of, 34
Tidal volume, spirometry values for, 436t for Guillain-Barré syndrome, 440, 440b Type I hypersensitivity response, in
Time-cycled pressure-limited (TCPL) in oropharyngeal aspiration asthma, 311–312, 312f, 313b
ventilation, for respiratory management, 474 Type II cells, formation of, 34
distress syndrome, 90, 90f in Robin sequence management, 243
Tissue expanders, in staged repair of
omphalocele, 229
for subglottic stenosis, 250
Tracheotomy(ies), 253–255
U
Underdevelopment, of pulmonary
Tissue test, for choanal atresia, 240 definition of, 253–254
vasculature, persistent
Tobacco smoke, as asthma trigger, 316 in epiglottitis, 420, 421
pulmonary hypertension of
Tobramycin, in cystic fibrosis in spinal muscular atrophy type 1
newborn from, 138
management, 370 management, decision making
Underwater positive expiratory pressure,
Tocolytic drugs on, 516–517
365b
contraindications to, 41b Transcutaneous monitoring, of blood gas
Universal precautions, 383b
during preterm labor, 41 status, 12, 13t
Urban living, as asthma risk factor, 310
in prevention of preterm delivery, 74 Transfusions, blood, for apnea of
U.S. Preventive Services Task Force
Toddler(s) prematurity, 116
(USPSTF)
with cystic fibrosis, high-frequency Transient tachypnea of newborn (TTN),
grading definitions of, 21, 21t
chest wall oscillation for, 361, 157–159, 157b, 158f
hierarchy of research design of, 21, 21b
363, 363f Transillumination, in tension
Uterus, overstretching of, spontaneous
normal vital sign values for, 9t pneumothorax diagnosis,
premature labor from, 67
social and language developmental 174–175
milestones for, 7 Transitional atrioventricular septal
TOF. See Tetralogy of Fallot (TOF) defects, 268 V
Tongue Transplantation, lung, in cystic fibrosis, Vaccination, mandatory, as ethical
in children vs. adults, 3, 4t 375 dilemma, 509
enlarged, 244 Transposition of great arteries (TGA), Vaccinations, influenza, for infants with
Tongue-lip adhesion, in Robin sequence 288–291, 288f wheezing/asthma, intramuscular
management, 243 clinical manifestations of, 289–290 versus intranasal, 346b
Tonsillar hypertrophy, 244, 244f course and prognosis of, 290–291 Valleculae, 246
Tonsils, in children vs. adults, 3, 4t management and treatment of, 290, Vallecular cysts, 246, 246f
Total anomalous pulmonary venous 290f Valvotomy, for aortic stenosis, 269
return (TAPVR), 285–288 pathophysiology of, 288–289 Valvuloplasty
clinical manifestations of, 287 Traumatic brain injury (TBI), 482–491 for aortic stenosis, 269
to coronary sinus, 286, 286f causes of, 482 for pulmonic stenosis, 270
course and prognosis of, 288 clinical manifestations of, 484–486 Variable decelerations, in fetal heart rate,
infracardiac, 286, 286f course and prognosis of, 491 47, 48f
management and treatment of, 287–288 first-tier therapy for, 488–489 Variable-flow CPAP, 84, 85t
mixed-type, 286 Glasgow Coma Scale in, 484, 485t neonatal, description of, 169t
pathophysiology of, 286–287 intracranial pressure in, 485–486. See Vascular endothelial growth factor
supracardiac, 285, 286f also Intracranial pressure (ICP) (VEGF)
Total body surface area (TBSA), of management and treatment of, 486–490 inhibitors of, for retinopathy of
burns, 467 extubation in, 490 prematurity, 207
Total lung capacity, spirometry values intubation in, 486–488, 487f, 488b in retinopathy of prematurity
for, 436t mechanical ventilation strategies in, progression, 205
Total obstruction of airways, by 489–490 Vascular resistance, in hypoplastic left
meconium, 152 neurogenic pulmonary edema in, heart syndrome, 291
Trachea 495–497 Vascular rings, complete, double aortic
abnormalities of, 2521–255 pathophysiology of, 482–484 arch as, 273
tracheoesophageal fistula as, 251–253, respiratory patterns in, 484, 484f Vasculature, pulmonary. See Pulmonary
252f respiratory system effects of, 483 vasculature
in children second-tier therapy for, 489 Vasodilators, pulmonary
endotracheal tube placement and, 5, 5f shaken baby syndrome and, 491b for congenital diaphragmatic hernia,
vs. adults, 3, 4t, 5 types of, 483, 483f 221–222, 222b
in children vs. adults, 3, 4t, 5 Triamcinolone acetonide (Azmacort), for for meconium aspiration syndrome,
masses of, 253 asthma, 332t 156
Tracheal occlusion, prenatal, for Tricuspid regurgitation, in Ebstein for persistent pulmonary hypertension
congenital diaphragmatic anomaly, 296, 297 of newborn, 142–144, 144b
hernia, 218–219, 218b Tricuspid valve repair, for Ebstein Venoarterial (VA) extracorporeal
Tracheitis anomaly, 298 membrane oxygenation, 146,
bacterial, 426–428. See also Bacterial Trismus, in tetanus, 442 146t
tracheitis Trisomy 13, omphalocele and, 228 initiation of, 147
exudative, 253 Trisomy 18, omphalocele and, 228 system for, diagram of, 147f
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Venous admixture, ABG sample errors Venturi mask, for oxygen delivery, 387t Volutrauma, from surfactant delivery, 168
from, 11–12 Vestibular stenosis, 241 Volvulus, with gastroschisis following
Venovenous (VV) extracorporeal Viability, fetal, cerebral development delivery, 227
membrane oxygenation, 146, and, 36–37 Vomer, nasal stents and, 240
146t Vibrations, in cystic fibrosis
initiation of, 147 management, 361 W
Ventilation Video fluoroscopy, in respiratory Weaning
collateral, in forced expiratory management of spinal cord from extracorporeal membrane
technique, 364 injury, 494 oxygenation, 150
in congenital diaphragmatic hernia Viral respiratory infections from high-frequency jet ventilation, 100
management as asthma trigger, 316 from high-frequency oscillatory
conventional, 220–221 bronchiolitis as, 382–393. See also ventilation, 99
high-frequency, 221 Bronchiolitis from mechanical ventilation,
previous strategies for, 220 early, as asthma triggers, 315 conventional, 96
control of, 113 pneumonia as, 393, 395, 395f, 395t. See terminal, terminal extubation versus,
dead space, in respiratory distress s also Pneumonia, viral 533–534
yndrome, 71 Virazole (ribavirin), in bronchiolitis Weight, estimation of, in emergencies, 8
definition of, 71 management, 390–391 Weight-for-age percentiles
gentle, in respiratory distress Virus(es) boys
syndrome, 95 causing bronchiolitis, 383 birth to 36 months, 26f
high-frequency. See High-frequency causing croup, 422 2 to 20 years, 28f
ventilation (HFV) causing pneumonia, 393 girls
mechanical. See Mechanical Viscous mucus, in asthma, 312 birth to 36 months, 27f
ventilation (MV) Viscous secretions, in cystic fibrosis, 359 2 to 20 years, 29f
noninvasive, for apnea of prematurity, Vital signs, in patient assessment, 8–9, Westley croup score, 423, 423t
116 9t–10t Wet drowning, 455
percussive, intrapulmonary, in cystic Vitamin A, for bronchopulmonary Wheezing
fibrosis management, 367 dysplasia, 125 in asthma, 317
positive-pressure. See Positive-pressure Vocal cord markers, for endotracheal in bronchiolitis, assessment of, 384t
ventilation (PPV) tube placement, 17, 17f in cystic fibrosis, 359
respiration differentiated from, 71 Vocal folds/cords, 244, 245f, 247. See also infants with, influenza vaccinations for,
Ventilation/perfusion (V/Q) mismatch Glottis intramuscular versus intranasal,
in bronchiolitis, 383, 384 nodules of, 248–249 346b
in pneumonia, 394 paralysis of, 248 Winged scapulae, in limb-girdle muscular
short-acting beta agonists and, 335b complicating coarctation repair, 272 dystrophy, 445b
Ventilator-associated pneumonia, Volume-assured pressure support Withholding neonatal resuscitation, 59
neurogenic pulmonary edema ventilation, 92 Wolff-Parkinson-White (WPW)
differentiated from, 496, 496t Volume-control ventilation syndrome, Ebstein anomaly
Ventilator CPAP, 84, 85t for acute respiratory distress and, 297, 297b
neonatal, description of, 169t syndrome, 404, 405f Wong-Baker FACES pain rating scale, 8,
Ventricle(s) for asthma exacerbation, 344 8f
development of, 36, 36f for respiratory distress syndrome, 91–92 Wood stoves, as asthma trigger, 316
right, hypertrophy of, in tetralogy of Volume guarantee (VG), 92 Work of breathing (WOB)
Fallot, 282 in intraventricular hemorrhage in CPAP effectiveness evaluation, 391
Ventricular septal defect (VSD), 266–267 prevention, 191 in infants
cardiac auscultation in, 263t Volume-targeted/adaptive ventilation obstruction increasing, 3
clinical manifestations of, 267 in intraventricular hemorrhage thoracic cage instability and, 5
course and prognosis of, 267 prevention, 191 thoracic mechanics and, in
inlet, 266 in pulmonary interstitial emphysema respiratory distress syndrome,
management and treatment of, 267 prevention, 171 71
muscular, 266, 266f for respiratory distress syndrome, 92 Wound botulism, 443
pathophysiology of, 266, 266f Volume-targeted pressure controlled
perimembranous, 266, 266f ventilation, for acute X
subarterial, 266 respiratory distress syndrome, Xanthines, for asthma, 333–334
in tetralogy of Fallot, 282 404–405, 405f
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