Question 1

The therapist is contemplating the possibility of intubating and suctioning a nonvigorous newborn with MAS. Which of the following clinical parameters confirms the indication for the procedure?

Accepted Answer

The AAP and AHA no longer recommend routine immediate endotracheal intubation and suctioning for nonvigorous infants. The care for these infants is guided by the same principles as outlined in NRP, in which intubation is indicated for inadequate respiratory effort (apnea, gasping, or poor oxygenation) or bradycardia despite bag mask ventilation, or when chest compressions are required.

Question 2

What is the typical type of airway obstruction that occurs with MAS?

Accepted Answer

If the infant has a large amount of thick meconium within the airways at the time of delivery, complete bronchiole obstruction with subsequent alveolar collapse will result. The more typical picture, however, is that of smaller amounts of meconium within amniotic fluid, causing a ball-valve effect because of partial obstruction of the airways.

Question 3

While reviewing the chest X-ray of a newborn recently delivered via cesarean section, the therapist observes the following features:
Pulmonary vascular congestion
Prominent perihilar streaking
Fluid in the interlobular fissures
Hyperexpansion
Flat diaphragm
Which of the following conditions does this patient likely have?

Accepted Answer

The chest radiograph shows pulmonary vascular congestion, prominent perihilar streaking, fluid in the interlobular fissures, hyperexpansion, and a flat diaphragm (see Figure 22-4 in the textbook). Mild cardiomegaly and pleural effusions may also be present.

Question 4

The therapist is reviewing the chest radiograph of a newborn, preterm infant and observes diffuse, fine, reticulogranular densities, which provide a ground-glass appearance. On the basis of these radiographic findings, which of the following conditions should the therapist suspect is present?

Accepted Answer

The chest radiograph in RDS typically reveals diffuse, fine, granular (reticulogranular) densities, which present a ground-glass appearance. The heart may be slightly enlarged, and the thymus is nearly always visible.

Question 5

Which of the following is the most common bacteria isolated in early-onset infection in term and near-term infants?

Accepted Answer

Organisms responsible for infectious pneumonia typically mirror those responsible for early-onset neonatal sepsis. Group B Streptococcus (GBS) was the most common bacterial isolate in most locales from the late 1960s to the late 1990s, when the use of intrapartum chemoprophylaxis began reducing neonatal and maternal infection by this organism. Despite the decreased frequency, GBS remains a common isolate in early-onset (age younger than 3 days) infections in term and near-term infants. Escherichia coli has become and continues to be the most common bacterial isolate among premature infants.

Question 6

Which of the following risk factors contribute to the pathogenesis of BPD?
I. Lung immaturity
II. Respiratory failure
III. Oxygen supplementation
IV. Positive-pressure ventilation

Accepted Answer

Northway and colleagues proposed four major factors in BPD pathogenesis: (1) lung immaturity, (2) respiratory failure, (3) oxygen supplementation, and (4) positive-pressure mechanical ventilation.

Question 7

What is the significance of an infant with RDS demonstrating a grunt during each exhalation?

Accepted Answer

A characteristic grunt during expiration is an attempt to maintain the FRC.

Question 8

Why does meconium staining occur predominantly in infants older than 36 weeks of gestational age?

Accepted Answer

Meconium passage into the amniotic fluid requires strong peristalsis and anal sphincter tone, which is not common in preterm infants. Meconium aspiration syndrome rarely occurs in infants born at less than 36 weeks of gestation. The longer a pregnancy is allowed to continue past 42 weeks, the greater the chances are of the passage of meconium.

Question 9

What ventilator settings should a therapist select for a newborn with respiratory distress syndrome? I. PIP 25 to 30 cm H₂O II. PEEP 4 to 6 cm H₂O III. VT 5 to 6 mL/kg IV. Frequency 20 to 40 breaths per minute

Accepted Answer

Generally, once the infant is stabilized in the NICU, a pressure-limited ventilator using a sinusoidal flow pattern is used. Peak inspiratory pressures (PIPs) generally adjusted at 15 to 25 cm H₂O, depending on the size of the infant and the severity of the disease, to establish a tidal volume (Vt) between 4 and 5 mL/kg. Positive end-expiratory pressure (PEEP) levels of 4 to 6 cm H₂O are used to prevent further alveolar collapse, and rates of 20 to 40 breaths per minute are used to treat hypercapnia. Inspiratory times (Ti) should be initiated at 0.3 to 0.4 seconds. If a longer Ti is required before surfactant administration, it should be lowered to 0.3 seconds after surfactant is administered. After surfactant administration, pulmonary compliance may improve rapidly requiring lower PIPs to attain similar tidal volumes.

Question 10

When neonatal pneumonia is suspected, how long does an infant generally receive broad-spectrum antibiotics?

Accepted Answer

Whenever neonatal pneumonia is suspected, broad-spectrum antibiotics are given for at least 48 hours, or until definitive culture results are obtained.

Question 11

Which of the following conditions increase the risk for developing RDS?
I. Maternal diabetes
II. Cesarean delivery
III. Multiple births
IV. Premature rupture of membranes

Accepted Answer

While the greatest risk factor for RDS is prematurity, other risk factors include maternal diabetes, multiple births, cesarean delivery, precipitous delivery, fetal asphyxia, cold stress, and a maternal history of previously affected infants, suggesting a genetic component. Incidence is higher in male and white infants.

Question 12

What radiographic features is the therapist likely to see on a typical chest X-ray of an infant with MAS?

Accepted Answer

The classic chest radiograph shows widespread patchy areas of atelectasis caused by obstruction, as well as hyperexpansion with flattening of the diaphragm secondary to air trapping.

Question 13

How should the therapist interpret the lack of supernatant foam appearing during the shake test?

Accepted Answer

Other tests for lung maturity have been developed; in the foam stability test, amniotic fluid is mixed with different volumes of 95% ethanol. When this mixture is shaken with air, a foam develops that can be seen for several hours at room temperature. If no surfactant is present, the foam will not appear or will appear only briefly, indicating the strong possibility of immature lungs. The shake test is not as specific as a low L:S ratio.

Question 14

What is the greatest risk factor for respiratory distress syndrome (RDS)?

Accepted Answer

While the greatest risk factor for RDS is prematurity, other risk factors include maternal diabetes, multiple births, cesarean delivery, precipitous delivery, fetal asphyxia, cold stress, and a maternal history of previously affected infants, suggesting a genetic component. Incidence is higher in male and white infants.

Question 15

Which of the following is the most common bacteria isolated in preterm infants?

Accepted Answer

Organisms responsible for infectious pneumonia typically mirror those responsible for early-onset neonatal sepsis. Group B Streptococcus (GBS) was the most common bacterial isolate in most locales from the late 1960s to the late 1990s, when the use of intrapartum chemoprophylaxis began reducing neonatal and maternal infection by this organism. Despite the decreased frequency, GBS remains a common isolate in early-onset (age younger than 3 days) infections in term and near-term infants. Escherichia coli has become and continues to be the most common bacterial isolate among premature infants.

Question 16

Which of the following therapeutic interventions is generally needed to treat transient tachypnea of the newborn (TTN)?

Accepted Answer

Treatment is largely supportive. The objectives of treatment of TTN are to maintain adequate oxygenation and ventilation. Supplemental oxygen via oxygen hood (usually <40%) is indicated when signs of respiratory distress are present. CPAP levels of 3 to 5 cm H₂O may be needed when higher FiO₂ levels are required.

Question 17

When should a therapist consider intubation and mechanical ventilation for a newborn with respiratory distress? I. Oxygen saturation less than 85% at FiO₂$\ge$40% on CPAP II. Periodic apnea III. PaCO₂ of 60 mm Hg or higher IV. pH <7.20

Accepted Answer

Typical indications for endotracheal intubation and mechanical ventilation are infants with respiratory failure or persistent apnea. Reasonable measures of respiratory failure are (1) arterial blood pH less than 7.20-7.25, (2) PaCO₂ of 60 mm Hg or higher, (3) oxygen saturation less than 85% at FiO₂$\ge$40% on CPAP, and (4) persistent apnea.

Question 18

When should a therapist consider CPAP for a newborn with respiratory distress?

Accepted Answer

If oxygen saturation cannot be kept in acceptable range by hood or cannula O₂, or if the patient develops excessive CO₂ retention or work of breathing, the next step in escalation of respiratory support is CPAP.

Question 19

How should the therapist interpret a lecithin-to-sphingomyelin (L:S) ratio of 2:1?

Accepted Answer

Lecithin, also known as dipalmitoyl phosphatidylcholine, is the most abundant phospholipid found in surfactant. RDS is unlikely if the L:S ratio is 2.0 or greater.

Question 20

Eight hours after being born, a baby presents with cyanosis despite administration of adequate ventilation, tachypnea, and retractions. Which of the following conditions should the therapist suspect is affecting this newborn?

Accepted Answer

PPHN should be suspected in all term infants who have cyanosis that may occur despite adequate ventilation. The recognition of risk factors for PPHN is one of the major diagnostic tools to differentiate babies with PPHN from those with structural heart disease, keeping in mind that idiopathic PPHN can present without signs of acute perinatal distress. Marked lability in oxygenation is frequently part of the clinical history. The infant with PPHN usually presents within the first 12 hours of life with cyanosis, tachypnea, and hypoxia that are refractory to oxygen therapy, as well as signs of respiratory distress, including retractions, grunting, and nasal flaring.

Quiz 22: Neonatal Pulmonary Disorders

The therapist is contemplating the possibility of intubating and suctioning a nonvigorous newborn with MAS. Which of the following clinical parameters confirms the indication for the procedure?

What is the typical type of airway obstruction that occurs with MAS?

The therapist is reviewing the chest radiograph of a newborn, preterm infant and observes diffuse, fine, reticulogranular densities, which provide a ground-glass appearance. On the basis of these radiographic findings, which of the following conditions should the therapist suspect is present?

Which of the following is the most common bacteria isolated in early-onset infection in term and near-term infants?

Which of the following risk factors contribute to the pathogenesis of BPD? I. Lung immaturity II. Respiratory failure III. Oxygen supplementation IV. Positive-pressure ventilation

What is the significance of an infant with RDS demonstrating a grunt during each exhalation?

Why does meconium staining occur predominantly in infants older than 36 weeks of gestational age?

What ventilator settings should a therapist select for a newborn with respiratory distress syndrome? I. PIP 25 to 30 cm H₂O II. PEEP 4 to 6 cm H₂O III. VT 5 to 6 mL/kg IV. Frequency 20 to 40 breaths per minute

When neonatal pneumonia is suspected, how long does an infant generally receive broad-spectrum antibiotics?

Which of the following conditions increase the risk for developing RDS? I. Maternal diabetes II. Cesarean delivery III. Multiple births IV. Premature rupture of membranes

What radiographic features is the therapist likely to see on a typical chest X-ray of an infant with MAS?

How should the therapist interpret the lack of supernatant foam appearing during the shake test?

What is the greatest risk factor for respiratory distress syndrome (RDS) ?

Which of the following is the most common bacteria isolated in preterm infants?

Which of the following therapeutic interventions is generally needed to treat transient tachypnea of the newborn (TTN) ?

When should a therapist consider intubation and mechanical ventilation for a newborn with respiratory distress? I. Oxygen saturation less than 85% at FiO₂ $\ge$ 40% on CPAP II. Periodic apnea III. PaCO₂ of 60 mm Hg or higher IV. pH <7.20

When should a therapist consider CPAP for a newborn with respiratory distress?

How should the therapist interpret a lecithin-to-sphingomyelin (L:S) ratio of 2:1?

Eight hours after being born, a baby presents with cyanosis despite administration of adequate ventilation, tachypnea, and retractions. Which of the following conditions should the therapist suspect is affecting this newborn?

Quiz 22: Neonatal Pulmonary Disorders

The therapist is contemplating the possibility of intubating and suctioning a nonvigorous newborn with MAS. Which of the following clinical parameters confirms the indication for the procedure?

What is the typical type of airway obstruction that occurs with MAS?

The therapist is reviewing the chest radiograph of a newborn, preterm infant and observes diffuse, fine, reticulogranular densities, which provide a ground-glass appearance. On the basis of these radiographic findings, which of the following conditions should the therapist suspect is present?

Which of the following is the most common bacteria isolated in early-onset infection in term and near-term infants?

Which of the following risk factors contribute to the pathogenesis of BPD? I. Lung immaturity II. Respiratory failure III. Oxygen supplementation IV. Positive-pressure ventilation

What is the significance of an infant with RDS demonstrating a grunt during each exhalation?

Why does meconium staining occur predominantly in infants older than 36 weeks of gestational age?

What ventilator settings should a therapist select for a newborn with respiratory distress syndrome? I. PIP 25 to 30 cm H2O II. PEEP 4 to 6 cm H2O III. VT 5 to 6 mL/kg IV. Frequency 20 to 40 breaths per minute

When neonatal pneumonia is suspected, how long does an infant generally receive broad-spectrum antibiotics?

Which of the following conditions increase the risk for developing RDS? I. Maternal diabetes II. Cesarean delivery III. Multiple births IV. Premature rupture of membranes

What radiographic features is the therapist likely to see on a typical chest X-ray of an infant with MAS?

How should the therapist interpret the lack of supernatant foam appearing during the shake test?

What is the greatest risk factor for respiratory distress syndrome (RDS) ?

Which of the following is the most common bacteria isolated in preterm infants?

Which of the following therapeutic interventions is generally needed to treat transient tachypnea of the newborn (TTN) ?

When should a therapist consider intubation and mechanical ventilation for a newborn with respiratory distress? I. Oxygen saturation less than 85% at FiO2 ≥\ge≥ 40% on CPAP II. Periodic apnea III. PaCO2 of 60 mm Hg or higher IV. pH <7.20

When should a therapist consider CPAP for a newborn with respiratory distress?

How should the therapist interpret a lecithin-to-sphingomyelin (L:S) ratio of 2:1?

Eight hours after being born, a baby presents with cyanosis despite administration of adequate ventilation, tachypnea, and retractions. Which of the following conditions should the therapist suspect is affecting this newborn?

What ventilator settings should a therapist select for a newborn with respiratory distress syndrome? I. PIP 25 to 30 cm H₂O II. PEEP 4 to 6 cm H₂O III. VT 5 to 6 mL/kg IV. Frequency 20 to 40 breaths per minute

When should a therapist consider intubation and mechanical ventilation for a newborn with respiratory distress? I. Oxygen saturation less than 85% at FiO₂ $\ge$ 40% on CPAP II. Periodic apnea III. PaCO₂ of 60 mm Hg or higher IV. pH <7.20