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Neonatal Respiratory System Neonatal Respiratory System 2 Neonatal Respiratory System Neonatal Respiratory System 2 Objectives Contents Upon completion of this course, the participant will Embryology and System Development 3 be able to: Transition from Intrauterine to • Describe the transition from intrauterine to Extrauterine Life 4 extrauterine life. Resuscitation of the Infant with • Identify the equipment that should be readily Respiratory Distress 6 available for a neonatal resuscitation. • Resuscitation Equipment . 6. • Resuscitation Procedure . 7. • List the medications recommended in the AAP/ AHA Neonatal Resuscitation Program. Differential Diagnosis 7 • Describe assessment and diagnostic strategies History and Respiratory System Assessment 8 of common neonatal respiratory disorders. Common Neonatal Respiratory Disorders 9 • Respiratory Distress Syndrome . 9 • Define nursing interventions for managing the infant with respiratory distress. • Transient Tachypnea of the Newborn . 12 • Meconium Aspiration Syndrome . .13 . Sandra L. Gardner, RN, MS, CNS, PNP • Pneumonia . 15. Director of Professional Outreach Consultation • Persistent Pulmonary Hypertension of Aurora, Colorado the Newborn . 16. Vicky L. Armstrong, RNC, MSN • Air-Leak Syndrome . 18. VP Neonatal Nursing Services • Congenital Diaphragmatic Hernia. 21 Nationwide Children’s Hospital • Apnea of Prematurity . 22. Columbus, Ohio • Chronic Lung Disease/Bronchopulmonary Dysplasia . .24 . Special Respiratory Concerns with the Premature Infant 28 Related Nursing Care 29 References 32 Additional Readings 33 Neonatal Respiratory System 3 Embryology and forces act on air-liquid interfaces, causing a water droplet to bead up. A surface-active compound System Development called surfactant reduces the surface tension There are five stages in the embryonic and allows the droplet to spread out into a thin development of normal lung growth: embryonic, layer. In the lungs, the surface-tension forces pseudoglandular, canalicular, terminal sac, and tend to cause the alveoli to collapse. Surfactant alveolar. As shown in Figure 1, the embryonic stage is needed to lower the surface tension within occurs from conception to week 5, with the major these alveoli to prevent their collapse at the end event being the formation of the proximal airways. of expiration. Surfactant is a surface-active agent The lung bud appears and begins to divide, the composed of phospholipids (including lecithin and pulmonary vein develops and extends to join the sphingomyelin), cholesterol, lipids, and proteins lung bud, and the trachea develops. In stage 2, the and is synthesized in type II alveolar epithelial cells. pseudoglandular stage, formation of the conducting These cells begin to appear in the lung between airways occurs (weeks 6–16). Cartilage appears 20 and 24 weeks of gestation. and the main bronchi form. Formation of new bronchi is complete and the capillary bed is formed. KEY LEARNINGS During the canalicular stage (weeks 17–24), the major feature is formation of acini (gas-exchanging » There are five stages in the embryonic sites). There is an appearance of cuboidal cells, the development of normal lung growth. capillaries invade the terminal air sac walls, type II alveolar cells appear, and the airway changes from » The final stage continues up to 8 years after glandular to tubular and increases in length and birth. diameter. The alveolar sacs are formed and there is development of gas-exchange sites in the terminal » The surface of the lung is lined by a layer of sac stage (weeks 25–37). In the alveolar, or final, fluid that creates an air-liquid interface. stage (week 37–postnatal), expansion of the surface area occurs. This stage continues up to 8 years » Surfactant is needed to lower the surface after birth. tension within the alveoli to prevent their collapse. The surface of the lung is lined by a layer of fluid that creates an air-liquid interface. Surface-tension Figure 1. The five phases of the process of tracheobronchial airway development. n = number of branches. Reproduced, with permission, from Leuthner SR: Anatomy and development of the lung. In Weisman LE, Hansen TN, eds: Contemporary Diagnosis and Management of Neonatal Respiratory Diseases, 3rd ed. © 2003, Handbooks in Health Care Co, p 2. Neonatal Respiratory System 4 Transition from Intrauterine to Figure 2. Fetal circulation. Extrauterine Life To head The transition from intrauterine to extrauterine environment and from fetal to postnatal life begins To arm To arm Superior Aorta with the clamping of the umbilical cord and the vena cava Ductus infant’s first breath. Pulmonary arteriosus artery Left atrium In utero, fetal circulation (Figure 2) depends on the Foramen ovale Right atrium placenta and three fetal ducts: the ductus venosus, Right Left Right lung the foramen ovale, and the ductus arteriosus. ventricle The placenta allows for the exchange of gases, Hepatic vein Left ventricle nutrients, and metabolic waste products. It is a Ductus low-resistance circuit that maintains a low fetal Liver venosus systemic vascular resistance, while the pulmonary Inferior fetal circuit maintains a high pulmonary vascular vena cava Renal arteries resistance. Subsequently, the increased pulmonary & veins Umbilical vascular resistance and low systemic vascular vein Portal Aorta resistance promote right-to-left shunting through vein the fetal ducts. The ductus venosus allows part of Umbilicus Umbilical the oxygenated blood carried by the umbilical vein arteries to bypass the liver. Oxygenated blood entering the heart flows through the foramen ovale into the left Hypogastric atrium, then perfuses the arteries Umbilical brain and the heart via cord To left leg the carotid, subclavian, Placenta Arterial blood and coronary arteries. Once the infant Venous blood Bladder Mixed arterial- The ductus arteriosus is delivered and venous blood directs blood from the the transition to main pulmonary artery to the descending aorta. extrauterine life Fetal admixture at the begins, respiratory subclavian, and coronary arteries before mixing foramen ovale and ductus and cardiovascular with blood shunted across the ductus arteriosus. arteriosus lowers fetal changes occur The remainder of the blood entering the right atrium arterial oxygen tension to mixes with blood from the superior vena cava and ~ 25–35 mm Hg. The low independently but continues into the right ventricle and pulmonary fetal oxygen tension helps simultaneously. arteries. Most of this blood shunts across the to maintain pulmonary ductus arteriosus into the descending aorta. artery vasoconstriction, allowing blood to bypass the lung and flow instead Once the infant is delivered and the transition through the foramen ovale and ductus arteriosus. to extrauterine life begins, respiratory and cardiovascular changes occur independently but In summary, fetal blood flows from the placenta simultaneously. Fetal lung fluid is replaced by air, via the umbilical vein, bypasses the liver via the so the liquid-liquid interface of alveoli becomes ductus venosus, and enters the inferior vena cava. an air-liquid interface and surface tension forces From the inferior vena cava, blood enters the begin. Surfactant decreases the surface tension right atrium, where the majority of it is shunted with the first breath and arterial oxygen tension through the foramen ovale into the left atrium. rises, resulting in reversal of hypoxemia-induced Blood continues into the left ventricle, where it pulmonary vasoconstriction. The pulmonary mixes with blood returning from the pulmonary vascular resistance begins to decline as a result veins, and is then injected into the ascending aorta. of increasing oxygen saturations and decreasing From the ascending aorta, it supplies the carotid, carbon dioxide levels, resulting in an increase in Neonatal Respiratory System 5 pulmonary blood flow. Decreasing prostaglandin ductus arteriosus closes functionally at 15–24 hours levels also will facilitate the reversal of the of age but does not close anatomically for 3–4 pulmonary vasoconstriction. Removal of the weeks (Tables 1 and 2). placental circuit by the clamping of the umbilical cord results in increasing systemic vascular KEY LEARNINGS resistance. Simultaneous cardiovascular changes include the closing of fetal shunts. The ductus » In utero, fetal circulation depends on the venosus functionally closes as the umbilical cord is placenta and fetal ducts. clamped. Functional closure of the foramen ovale occurs at birth from the changing atrial pressures » Low fetal oxygen tension allows blood to and increasing systemic vascular resistance. The bypass the lung. left atrial pressure is now greater than the right atrial pressure. With increasing arterial oxygen tension » At delivery, respiratory and cardiovascular and decreasing levels of prostaglandin E, the changes occur independently but simultaneously. Table 1. Summary of Main Transitional Events from Fetal to Neonatal Circulation Loss of fetal lung fluid Secretion of surfactant Establishment of functional residual capacity Fall in pulmonary vascular resistance Rise in systemic vascular resistance Closing of fetal shunts Increasing pulmonary blood flow Table 2. Transition from Fetal to Neonatal Circulation First Period of Reactivity Period of Relative Inactivity Second Period of Reactivity (early reactivity) (deep sleep) (secondary reactivity) Time Course Birth to 30–45 minutes 45 minutes to 2–4 hours 3–4 hours thereafter CNS Alert, eyes open; vigorous, active Somnolent, eyes closed; Hungry; progresses normally crying; increased tone
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