Perinatal & Pediatric Respiratory Care

FALL 2006
 NORTHEASTERN UNIVERSITY BOUVE COLLEGE OF PHARMACY AND HEALTH SCIENCES
 INTRODUCTION TO PERINATAL/PEDIATRIC RESPIRATORY CARE

LECTURE

CES U604

Day #: | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | final |

Course Description- Lecture

Faculty

Michael R.A. Jackson RRT CPFT NPS Phone: 617.680.0152
Lauren Perlman RRT Children's Hospital

Lecture Class Meeting Time

Thursday

Time off:

October 9 - Colombus

November 23  - Thanksgiving 

Finals December 14

Lecture Book

·         Whitaker, Kent. Comprehensive Perinatal & Pediatric Respiratory Care
3rd. Ed., Albany, NY Delmar, 2001 ISBN 0766813738

·         Manual of Neonatal Resuscitation 5th ed., American Heart Assn.

Lecture Examinations/Evaluations

Lecture Study Topics, Objectives & Reading Assignments 

[top]Lecture 1 ( Week 1 Sept. 11, '06)

Introduction to the Course
Newborn Resuscitation
Reading: American Heart Assn. American Academy for Pediatrics Newborn Resuscitation Manual (4th Edition)

Embryologic & Fetal Development Cardiopulmonary System

  1.  Describe the embryology and the approximate time of development of the morula, blastocyst,blastoderm, and trophoblast.
  2. Identify the three germ layers and the body structures that evolve from each
  3.  Identify the four periods of embryonic lung growth and describe the major milestones of each period
  4.  Summarize the three Reid's rules regarding lung growth. Describe the general lung development that takes place after birth.
  5. Explain the functions of the amnionic fluid and define the following:
    1. polyhydramnios
    2. oligohydramnios

�  Visible Embryo http://www.visembryo.com/baby/hp.html

�  Basic Embryology Review http://www.med.upenn.edu/meded/public/berp/

�  Michael J Embryo http://msrcol.org/nu/embryo.html

�  14 mm embryo lung branching

�  REID's RULES for FETAL DEVELOPMENT

�  generations of airway branching

�  Cardiac Embryogenesis
Obstetric Ultrasound (Hong Hong)
http://www.w-cpc.org/pictures/adam/mo2.JPG
http://www.mhhe.com/socscience/sex/common/ibank/set-5.htm
http://www.hdrc.org/
http://www.med.unc.edu/embryo_images/unit-welcome/welcome_htms/akgs.htm
http://embryo.soad.umich.edu/
http://health.discovery.com/convergence/ultpregnancy/video.html
http://anatomy.med.unsw.edu.au/cbl/embryo/wwwhuman/HumHome.htm
http://www.med.upenn.edu/meded/public/berp/overview/BV_1.html
http://biology.about.com/gi/dynamic/offsite.htm?site=http%3A%2F%2Fwww.pbs.org%2Fwgbh%2Fnova%2Fodyssey%2Fclips%2F
http://www.pbs.org/wgbh/nova/odyssey/
http://www.millerandlevine.com/km/evol/embryos/Haeckel.html
http://www.nobel.se/medicine/laureates/1995/illpres/consequences.html
http://www.bioscience.org/atlases/fert/images/drawings/ovul.jpg
http://www.sptimes.com/News/112001/photos/pulse-embryo.jpg

 

[top] Lecture 2 ( Week 2 Sept. 15, '06)

  1. Regarding fetal lung fluid, describe the following:
    1. Composition
    2. Function
    3. The hazards of lung fluid retention
  2. Describe the embryonic development of the heart including:
    1. Development of the cardiac chambers
    2. Formation of major vessels and cardiac chambers
  1. With regard to fetal circulation, describe and explain:
    1. The cause of pressure differences between the right and left heart.
    2. The flow of blood from the placenta, trough the body, and back to the placenta
    3. Each shunt that is encountered with the approximate amount of blood that passes each shunt.
  1. Given an approximate history, determine whether a pregnancy is high risk.
  2. Discuss the effects of maternal age on pregnancy risk.
  3. Describe the features of toxemia of pregnancy.
  4. List the conditions related to uteroplacental insufficiency.
  5. Describe the possible results of uteroplacental insufficiency.
  6. Describe the possible effects fo maternal infection with rubella, toxoplasmosis, herpes,cytomegalovisis, and syphilis on the fetus.
  7. List and describe maternal anatomic abnormalities which may increase fetal risk.
  8. Describe how ultrasonography is used to assess fetal status.
  9. Explain the possible effects of maternal diabetes on fetal development in general and on lung maturation in particular.
  10. Define Teratogenensis . Describe the effects of the abuse of such teratogens as tobacco, marijuana, cocaine and alcohol.
  11.  Define amniocentesis and describe the role of each of the following
    1. L/S ratio
    2.  Determination of alpha-fetoprotein
    3.  Bilirubin level
    4.  Creatinine level
    5.  identification of meconium staining
    6.  cytologic examination of cells
  1. Review maternal history antenatal & prepartum
    1. Stress testing
    2. Lung maturity premature and/or premature rupture of membranes, anesthesia, medications, presence of meconium

Reading Assignment: Whitaker, pp. 3-10; 15-25 EMBRYO pp. 225 Maternal Drug Abuse ...........................................................................

 

The High Risk Pregnancy: Assessment of Fetal Growth and Development
Labor, Delivery, and Physiologic Changes After Birth

�  -Stages of Normal Labor and Delivery

�  -Abnormal Labor and Delivery
-Adaptation to Extrauterine Life

  1. List and describe the different methods of measuring fetal heart rates and describe the cause and characteristics of the following:
    1. baseline heart rate
    2.  bradycardia
    3.  tachycardia
    4.  beat-to-beat variability
    5.  accelerations
    6.  decelerations
  2. Explain how fetal scalp pH is used to assess fetal asphyxia
  3. List and describe the five methods used to estimate the date of delivery.
  4. Compare and contrast the contraction stress test with the non-stress test. Describe how each is performed and the advantages and disadvantages.
  5. Describe the use fetal movements as methods of assessing fetal well being.
  6. Describe the six tests used in the biophysical profile.
  7. Discuss the implications of meconium stained amnionic fluid in assessing fetal well being.
  8. Describe the basic process of cervical dilatation and effacement. Identify the most common presentation.
  9. Define station and how it is expressed. Describe the sequence of events that lead to the descent and delivery of the fetus.
  10.  Define tocolysis and describe the various methods used to achieve tocolysis .
  11.  Define dystocia and describe the three etiological factors that cause it.
  12.  Describe each of the following types of presentation
    1. complete breech
    2. incomplete or footling breech.
    3. frank breech
    4. face presentation
    5. transverse lie
    6. prolapse of the umbilical cord and occult cord compression.
  1. Identify and describe the three types of placenta previa.
  2. Describe the three categories of abruptio placentae and discuss treatment.
  3. Discuss the issues and risks associated with premature rupture of membranes (PROM)
  4. List the indications for Cesarean birth
  5. Discuss the problems of multiple gestation in high risk pregnancies.
  6. Explain what occurs in discordant and parabiotic twinning.
  7. List the factors that are responsible for the first breath
  8. Describe the importance of overcoming surface forces in adapting to extrauterine life.
  9.  Identify and describe factors that cause the change from fetal to the adult crculation
  10. Reading Assignment: Whitaker pp30-46 111-130  L&D webpage (http://msrcol.org/nu/l&d.html)


Delivery and Assessment of th Newborn

  1. birth anomalies
  2. oligo & poly-hydramnios
  3. Mike J Labor & Delivery
  4. Rgestational age, birth weight, physical findings, APGA scores, breathing pattern

 

[top]Lecture 3 ( Week Sept. 18, '06)
Surfactant Deficiency & Severe Prematurity

  1.  Define surface tension and describe the following:
    1.  How it is developed
    2. Laplaces law
    3. application to alveolar mechanics.

Discuss the role of surfactant in pulmonary physiology
Identify the major componants of pulmonary surfactant and explain their function

  1.  Discuss the risk factors associated with the development of respiratory distress syndrome (RDS).
  2. List and describe the abnormalities typically associated with RDS
  3.  Describe the pathopyhysiology of RDS. Explain why alveolar hyaline membranes are formed.Describe the vicious cycle which contributes to the deteriorationg clinical condition of the infant with RDS.
  4. Outline the clinical features of RDS and describe the usual clinical course.
  5.  Given a case description of a patient with typical but severe care of RDS, identify key steps in the proper treatment and management.
  6.  List the disorders which frequently accompany RDS or are complications of treatment
  7.  Describe the essential features foan effective exogenous surfactant
  8.  Describe the many types of exogenous surfactant.
  9. Define hysteresis and describe and justify the shape of a normal hysteresis curve. Explain how a decreased pulmonary surfactant would affect the hysteresis curve.
  10.  Identify the normal values for functional residual capacity (FRC), pulmonary compliance, airway resistance, tidal volume, minute ventilation, deadspace, and alveolar ventliation of the term newborn. Explain how these values change with age.
  11. Explain what is meant by time constants and the consequences of decreased expiratory time.
  12. Explain the effecte of decresaed compliance and increased airway resistance on tidal volume and respiratory rate in the newborn.
  13. Describe the differences between the adult and the newborn infant with regard to ventilation/perfusion ratio, diffusing capacity, and hemoglobin type.
  14.  Discuss the consequences of increased fetal risk and identify the extrapulmonary complications of prematurity in the neonate. Discuss IUGR and distinguish between the two types.

 


 Reading Assignment
Whitaker pp 10-15 Surface forces and the role of surfactant pp 294-299 458-469 Respiratory Distress Syndrome


Chest Disease at Virtual Hospital


Reading Assignment: Whitaker pp10-15, 53-71
...........................................................................

Transient Tachypnea & Pneumonia

  1.  -Transient Tachypnea of the Newborn
  2. -Pneumonia
  3. -Meconium Aspiration
    1. Discuss the etiology of transient tachypnea of the newborn (TTN) and identify the types of neonates and the perinatal situations which give rise to this problem.
    2. Describe the typical presentation and progression of TTN.
    3. Explain how TTN is diagnosed. Describe the typical chest x-ray findings.
    4. Given a typical TTN case, discuss how the patient should be managed.
    5. Distinguish between early onset and late onset neonatal pneumonia. Compare the two types' response to treatment. Explain the ways in which transmission of pathogens can occur in the neonate.
    6.  Identify the most common causative organism for neonatal pneumonia. Identify the complications that occur with this pneumonia. Identify other transplacental and perinatally acquired organisms.
    7. Identify causative organisms for late onset pneumonia. Discuss the ways in which pathogenbs are transmitted.
    8. Describe the clinical presentation,the most frequently encountered clinical issues,the typical x- ray findings, and the general management of the neonate with pneumonia.
    9. Identify the conditions which predispose a neonate to the meconium aspiration syndroome (MAS). Describe the meconium material.
    10. Discuss the do's and don'ts for the delivery room management of the meconium stained infant.
    11. Identify key areas in the management of the MAS infant. Contrast the various clinical scenarios that could occur with MAS. Explain the limitations of conventional interventions and why they sometimes fail.

Chest Disease at Virtual Hospital

Reading Assignment: Whitaker. pp 322 (TTN), 386-387 (pneumonia), 312-316, 474-506 Mechanical Ventilation, 557-560, 602-605 Home Ventilation, 135-140 Pulmonary Function Testing (meconium aspiration)

[top]Lecture  4 ( Week Sept. 25, '06)

Complications of Prematurity

  1. Define retinopathy of prematuriy (ROP) and explain in general terms the nature of this disease. Identify the risk factors for developing ROP.
  2. Describe the process by which ROP develops. Describe the five stages of ROP. Identify the ways in which the disease is treated.
  3. Distinguish between intracranial and intraventricular hemorrhage in terms of the gestational ages they affect and the area of the brain in which they are present.j
  4.  Summarize the physiological reasons by which intracranial and intraventricular hemorrhages develop. List the contributory factors of intraventricular hemorrhage.
  5. Outline the clinical signs that may be present in the neonate who is developing and intraventricular hemorrhage (IVH).
  6. Explain how long-lasting complications from IVH are managed. Explain how the condition known as posthemorrhagic hydrocephalus (PHH) develops and how it is treated.
  7.  Identify the infant who is at risk for necrotizing enterocolitis (NEC). Explain how NEC is diagnosed and how the infant on "NEC watch" is managed.
  8. Describe the pathophysioloy of NEC and the treatment.

Reading Assignment: Whitaker, pp. 170-171, 214-216 (NEC), 299-312
Additional Issues in Prematurity
http://picubook.fbm.msu.ru/All-Net/french/pulmpage/neon/mecasp.html
http://www.vh.org/Providers/TeachingFiles/PAP/NeonatalChestDiseases/MecAsp.html
http://matweb.hcuge.ch/matweb/Selected_images/Developmental_genetic_diseases/meconium_aspiration.htm
http://edcenter.med.cornell.edu/CUMC_PathNotes/Pediatrics/Pediatric.html
Adult/Fetal hemoglogin
Adult/Fetal Surgery
http://www.cayuga-cc.edu/greer/biol204/heart4/heart4.html
http://www-medlib.med.utah.edu/WebPath/PEDHTML/PEDIDX.html
http://www.med.jhu.edu/peds/neonatology/neo/ResidentGuidebook/resp.htm#Resp
http://pediatricradiology.com/
http://www-medlib.med.utah.edu/WebPath/PEDHTML/PEDIDX.html

 

Air Leak

  1. List the types of air leak syndromes that occur frequently in the neonate. Explain the pathophysiology of each of the types.
  2. Identify the types fo pulmonary interstitial emphysema (PIE). Explain how PIE develops and how it can be prevented or minimized. Describe the pathophysiology.
  3. Explain ways in which pneumothorax can develop. Discuss the difference between spontaneous pneumothorax and tension pneumothorax.
  4.  Discuss how pneumothorax can be diagnosed. Decribe the signs and symptoms. Explain how the transilluminator is used to diagnose pneumothorax.
  5.  Describe the emergency and non-emergency treatment of pneumothorax.
  6. Differentiate pneumomediastinum from pneumothorax and discuss the treatment.
  7. Neonatal Airway

�   -Congenital Anomalies Involving the Airway

�  -Infectious Disease Involving the Airway


http://www.neonatology.org/ref/thermal.html
http://www.peds.umn.edu/divisions/neonatology/spnicu/guide.html
http://www.neonatology.org/syllabus/ger.html
http://www.kumc.edu/kumcpeds/cardiology/pedcardio/pdadiagram.gif
http://www.cs.nsw.gov.au/rpa/neonatal/html/newprot/newpda.HTM
http://www.kumc.edu/kumcpeds/cardiology/pedcardioecho/patentductuscd.gif
http://edcenter.med.cornell.edu/CUMC_PathNotes/Pediatrics/4457.gif
http://neonatal.peds.washington.edu/NICU-WEB/prophylaxis.stm
http://www.cheo.on.ca/bpd/BPDindx.html
http://www-medlib.med.utah.edu/WebPath/PEDHTML/PED216.html
http://neonatal.peds.washington.edu/NICU-WEB/bpd_mort.asp
http://www.neonatology.org/syllabus/dp.html
http://www-medlib.med.utah.edu/WebPath/PEDHTML/PEDIDX.html
http://www.neonatology.org/syllabus/pierre.robin.html

  1.  Define neonatal jaundice and discuss its prevalence in the newborn population. Explain in basic terms why neonatal jaundice is problematic,differentiating between physiologic and non- physiologic jaundice.
  2.  Identify the source of bilirubin and explain in basic terms how unconjugated bilirubin becomes conjugated. Explain what can happen to allow persistently high serum levels of unconjugated bilirubin
  3.  List the common issues that occur in the neonate that can lead to hyperbilirubinemia .


 Discuss the dangers and complications of jaundice. Explain what is meant by kernicterus. Outline the basic treatments.

  1. Reading Assignments: Whitaker, pp. 316-319 (PIE), 210-214 (Jaundice)  

[top] Lecture 5 ( Week Oct. 2, '06)
Apnea

SIDS

Apnea

Apnea

 

  1. Describe the type of child who has obstructive sleep apnea. Discuss some of the major treatments for this problem.
  2. Define sudden infant death sydrome (SIDS) and identify the age group affected. Explain how a diagnosis is made.
  3. Explain why SIDS is sometimes called a development disorder. Identify the major risk factors for the syndrome. Explain how the risks for SIDS can be minimized. Discuss the position theory.
  4. Explain what is meant by an ALTE and how a patient affected by SIDS can become an intensive care admission.
  5.  Discuss the types of congenital tracheoesophageal fistulas.
  6. Explain what is meant by esophageal atresia. Describe the signs seen in the newborn that may lead to a suspicion TEF.
  7. Explain how the infant with TEF should be positioned.
  1. Discuss the signs of choanal atresia and explain how the affected infant should be managed before surgical repair. Explain what is meant by apnea fo prematurity. List the three types of apnea.
  2.  Describe the mechanism to which the cause of apnea of prematurity is attributed.
  3.  Explain when most episodes fo apnea occur. Identify the common disorders which are reported to precipitate apnea of prematurity.


Explain how the infant who is prone to apnea spells is cared for and monitored. State the target theophylline level range.

http://neonatal.peds.washington.edu/NICU-WEB/apnea.stm
http://neonatal.peds.washington.edu/NICU-WEB/apnea_guidelin.stm
http://www.neonatology.org/syllabus/apnea.html
http://odp.od.nih.gov/consensus/cons/058/058_statement.htm

 

Retinopathy

 

Whittaker pp. 323-326 (Apnea)


Midterm Review

 

Lecture 6 (Week Oct. 9, 06)

Midterm

 

 

[top]Lecture 7 (Week Oct. 16, '06 )

Airway Anomalies in the Infant and Child

  1. Define stridor . Given the type of stridor, identify where in the airway an  obstruction is likely to be located.
  2. List the types of supraglottic airway abnormalities.
  3. Identify those types of obstructions that interfere with obligate nasal breathing. Explain how an infant with bilateral nasal obstruction might behave.
  4. Define choanal atresia and explain why this conditions affects obligate nasal breathing. Explain how the condition is clinically diagnosed.
  5. Define CHARGE syndrome by explaining the acronym.  Explain the airway issues in this syndrome.
  6. Explain how crainiofacial dysmorphology may produce airway obstruction and other difficulties. List the three most common types of crainiofacial dysmorphology syndromes.
  7. Describe the characteristics of Pierre Robin, Treacher Collins, and Apert's syndrome.
  8. Describe the main feature of Beckwith Wiedemann syndrome and explain how airway obstruction occurs in this syndrome.
  9. Explain how and why Down's syndrome is associated with upper airway obstruction.
  10. Explain how hemangiomas and neuroblastomas can be associated with airway obstruction.
  11. Define laryngotracheomalacia and identify its cause.  Describe its usual presentation and usual course.
  12. List and describe those disorders which obstruct the airway at supraglottic, glottic, and subglottic areas. Where appropriate, discuss the causes of these disorders, the signs and symptoms, the clinical manifestations, and the treatment.
  13. Define tracheoespophageal fistula and espohageal atresia.  Describe the two most common presentations of these anomalies. Discuss the signs and symptoms, diagnosis, and respiratory implications of this disorder. Identify theanacronyms VATER and VACTERL, and explain their association to tracheoespophageal fistula and espohageal atresia.
  14.  Identify the major congenital anomalies which produce airway obstruction.
  15.  Explain how stridor is produced. Explain how the character of stridor differs with partial obstructions at different locations in the airways.
  16.  In the child with laryngomalacia describe the structural abnormalities and discuss the prognosis and management.
  17.  In the child affected by vocal cord paralysis, explain under what conditions airway obstruction is likely. Discuss the potential causes of vocal cord paralysis and the treatment and prognosis.
  18.  Identify the causes and describe the basic abnormalities found in subglottic stenosis, tracheal stenosis, and tracheomalacia. Discuss the management of patients affected by these problems.
  19.  Identify the airway structures that are affected by epiglottitis. Explain how this di

Pierre Robin Sequence

Tracheoesophageal Fistula

Electric Airway (list of sites)

Chest Disease at Virtual Hospital

Whittaker pp. 345-348 (TE fistula), 607 Apnea Monitoring

Croup Epiglottitis Bronchiolitis

  1. Dissease is diagnosed. Explain how an airway emergency can arise from this problem. Discuss the cause, presentation, and treatment of epiglottitis .
  2.  Distinguish between croup and epiglottitis. Identify the three types of croup.
  3.  In discussing the three types of croup,m identify the presumed causes of theis disease. Discuss the patient history for each type and explain how a diagnosis is made. Discuss the treatment.

�  Whittaker 397 (SIDS), 345-348 (choanal atresia)

�  http://surf.to/neon croup epiglottitis page 

 

[top]Lecture 8 ( Week Oct 31, '06)-

Surgical Disorders in the Newborn and Child

  1.  1. For each of the following pulmonary lesions, explain exactly what they are and discuss the potential causes, potential complications, and treatment issues:
    • congenital adenomatoid malformation (CAM)
    • bronchogenic cysts
    • congenital lobar emphysema
    • sequestration
    • congenital diaphragmatic hernia (CDH)
    • Gastroschisis
    • -Omphalocele

 

  1. Describe congenital diapharagmetic hernia and define the paradigm. Explain how an to what degree ventilation is compromised in CDH.
  2. Discuss the diagnosis and delivery room management of CDH. Describe the ventilation strategies used in treating CDH.
  3. Describe additional treatment measures for CDH in addition to or beyond mechanical ventilation.
  1. Omphalocele
  2. Omphalocele & Gastroschesis
  3. Omphalocele & Gastroschesis
  4. Omphalocele & Gastroschesis
  5. Distinguish between the definitions of gastroschisis and omphalocele . Discuss how both of these problems are thought to develop.
  6. Discuss the complicating issues that are present in infants with either gastroschisis or omphalocele. Explain what is involved insurgical repair and athe short and long term pulmonary issues. Explain how the infant should be managed on the ventilatory before and after surical repair.
  7. Chest Disease at Virtual Hospital
  8. http://cpmcnet.columbia.edu/dept/pulmonary/lungtx.html

Reading Assignment: Whitaker, pp.345-348 (CDH); 

Neuromuscular Disease

  429 (CLE), 384-386 (Reyes)

 

Lecture 9 ( Week Nov. 6, '06)

 

Cystic Fibrosis

  1. Explain what occurs physiologically in cystic fibrosis (CF). Define meconium ileus syndrome and relate this to CF. Describe the progression of CF and explain how it affects non- respiratory systems.
  2. Identify the infectious organisms that affect CF patients and explain why infection is problematic in advancing the disease.
  3. Discuss the treatment elements for cystic fibrosis. Review the basis for every type of treatment. Discuss some of the newer approaches to respiratory care, and point out the experimental interventions.

 373-378 (CF)

 

 

Asthma

 

 

[top]Lecture 10  ( Week Nov. 13, '06)

Nitric Oxide PPHN High Frequency Ventilation ECMO

Cardiac Anomalies 1: Defects that Increase & Decrease Pulmonary Blood Flow

�   Identify the major cardiac anomalies that alter pulmonary/systemic hemodynamics. For each of the anomalies describe the basic defect in anatomy and its effect on hemodynamics .
Discuss signs and symptoms of infants affected by these disorders.


 

 

[top]Lecture 11 (Thurs. Nov. 30, '06)

Cardiac Anomalies 2: Defects that Increase & Decrease Pulmonary Blood Flow

�   Identify the major cardiac anomalies that alter pulmonary/systemic hemodynamics. For each of the anomalies describe the basic defect in anatomy and its effect on hemodynamics .
Discuss signs and symptoms of infants affected by these disorders.

 

[top]Lecture 12 (Week Dec. 4, '06)

Final Review

 

 

[top]Lecture Final (13) (Week Dec. 11, '06 )
Final Examination

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