Question

A term (41 weeks) female weighing 3100 g was born to a 30-year-old healthy gravida 2 para 1 mother by cesarean. Apgar scores were 9 and 9 at 1 and 5 minutes. The infant was initially well until day 3 of life, when she presented with tachypnea and increased work of breath- ing, including retractions and nasal flaring. The infant was transferred to the NICU. A complete sepsis workup was done and antibiotics were given as protocol. The infant was placed on a nasal cannula for oxygen saturations which ranged from 89-91%. A capillary blood gas was performed and revealed the following: pH 7.30, PaCO2 56 mm Hg, PaO2 45 mm Hg, HCO3 27 mEq/L, and BE 1. A chest radio- graph showed mild hyperinflated lungs and mild perihilar interstitial markings. An echocardiogram was also ordered at this time, which showed an anatomically normal heart with no structural malformation. During the next 24 hours, the infant’s respiratory status worsened, with progressive increases in work of breathing with increasing oxygen requirement. Continuous positive airway pressure was initiated by nasal mask at 6 cm H2O and an FIO2 of 0.50. A follow-up chest radiograph was performed, which showed increasing haziness of both lung fields with air bronchograms. Capillary blood gases obtained 12 hours after nasal CPAP therapy revealed the following: pH 7.19, PaCO2 80 mm Hg, PO2 40 mm Hg, HCO3 29.5 mEQ/L, BE 1.8, and oxygen saturation 88%. Physical assessment revealed the following: tempera- ture 37.1°C, heart rate 175 beats per minute, respiratory rate 90 breaths per minute, and blood pressure 70/40 mm Hg. The infant was intubated and mechanically ventilated with an inspiratory pressure of 20 cm H2O, PEEP 6 cm H2O, set rate of 60 breaths per minute, and FIO2 of 0.80. Systemic examination was unremarkable except for respiratory distress. There was no clinical evidence of pulmonary hyper- tension. A complete sepsis workup was repeated. The white blood cell count was unremarkable. Chest radiograph following intubation revealed diffuse ground-glass appearance with air bronchograms. The endotracheal tube was 2 cm above the carina.

1. What therapeutic recommendation would you make based on the infant’s clinical presentation and chest radiograph?

THIS QUESTION IS FOCUSED MORE TOWARDS RESPIRATORY THERAPY!

Answer 1

The respiratory problems is the most common problem in neonates. Most of the neonate maintaining good respiratory function after birth with out assistance but 10%of neonates need assistance for breathing and maintaining good respiratory status.

The factors affecting  respiratory function of neonates are,

:the neonate have small airway.

:they have Complaint chest wall

:collateral airways are less

:poor airway stability

:low functional residue capacity.

The main respiratory problems in neonates include respiratory distress syndrome ,transient tachypnea, maconium aspiration syndrome ,pneumothorax ,pneumonia etc

Effective management and close monitoring is needed to regain respiratory function of this patient.

Therapeutic recommendation for this patient include

:close monitoring of patient :close monitoring of respiratory status is necessary to prevent complication and maintain good health status. Monitor vital signs, oxygen saturation to detect complication as early as possible.

:freequent suctioning to prevent blockage of airway.

:correct size and correct placement of endotracheal tube___correct placement and correct size of ET tube is necessary for minimize air way resistance and lung injury.

The endotracheal tube wants broader inner area in order to seal to the trachea and provide adequate ventilation. The placement of ETT is important because incorrect placement of ETT leads to atlectasis and lung collapse. Ideal safe position for the ETT in neonates are ,the tip is the midtracheal position ,usually at T1 - T2 level .

:positioning ___proper positioning help to improve lung function. Most of the studies show that the prone position help to improve oxygenation. The slight elevation of head is also improve ventilation.

:respiratory kinesiotherapy___this is a good techniques for improving lung function. The technique involve in respiratory kinesiotheraphy include,

Positioning

Postural drainage

Active techniques like vibration and percussion.

The airways of neonate is different from adults .Few amount of sputum cause blockage of airway, respiratory kinesiotherapy help to clear secretion and improve lung function .The therapy is done under proper positioning such as prone position and postural drainage started. This will help to clear secretion.

Benefits of respiratory kinesiotherapy

Improve lung function

Help to clear secretion

Increase function of heart

Increase muscle strength

Help to eliminate stagnation

Improve sputum drainage

Improve ventilation by increasing circulation in arteries of lung.

:aerosolization and nebulization___this will help to administer medication at correct dose and effective way and nebulization help to clear the secretion.