Perinatal Program for NUSpring 1998
NORTHEASTERN UNIVERSITY BOUVE COLLEGE OF PHARMACY AND HEALTH SCIENCES
INTRODUCTION TO PERINATAL/PEDIATRIC RESPIRATORY CARE
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Course Description- Lecture
This course begins with an overview of human cardiopulmonary development from the time of conception through the childhood years. Normal and abnormal manifestations of pregnancy, labor and the process of delivery are then discussed with an emphasis on those factors which compromise the cardio-respiratory
health of the neonate. Respiratory care of the acutely ill neonate and the acutely and chronically ill infant and pediatric patient is a major focus on the course with much exploration into methods of assessment and trends in current practice. Some associated non-cardiopulmonary disorders of prematurity are considered, and there will be some examination and discussion of the common congenital cardiac anomalies. This course closely parallels and complements the laboratory course, CPS 1404
Michael R. Jackson RRT, CPFT, Perinatal/Pediatric Specialist
Brigham & Women's
Beeper (alphanumeric) 617-732-5656 # 15948
Lecture Class Meeting Time
Whitaker, Kent. Comprehensive Perinatal & Pediatric Respiratory Care, Albany, NY Delmar, Second Edition 1996
A list of objectives for each study topic will be distributed, usuallly at the beginning of each class
meeting. Class discussions and examinations will focus on these objectives. It is the student's
responsibility to meet all objectives, utilizing arterial presented in class, handouts, and assigned reading
and videotape programs.
Two examinations are scheduled. The first will be at mid quarter. A final examination will evaluate the
remainder of the study topics. This examination will be given during the final exam week according to the published schedule.
- Fifteen percent of the course grade will be based on attendance and participation at class meetings.
- Four videotaped presentations will be assigned for viewing outside of class. A list of objectives for each
presentation will be available. There will be some class discussion of these videos and questions relating
to them will be included in examinations.
The final grade for the course will be according to the following distribution:
Mid Term Examination 40%
Final Examination 45% June 8 - 12
Lecture Study Topics, Objectives & Reading Assignments
Embryological Development of the Fetal Cardiopulmonary System
Describe the embryology and the approximate time of development of the morula, blastocyst,blastoderm, and trophoblast.
Identify the three germ layers and the body structures that evolve from each
Identify the four periods of embryonic lung growth and describe the major milestones of each period
Summarize the three Reid's rules regarding lung growth.
Describe the general lung develpment that takes place after birth.
Regarding fetal lung fluid, describe the following:
- The hazards of lung fluid retention
Describe the embryonic development of the heart including:
- Developmenit of the cardiac chambers
- Formation of major vessels and cardiac chambers
With regard to fetal circulation, describe and explain:
- The cause of pressure differences between the right and left heart.
- The flow of blood from the placenta, trough the body, and back to the placenta
- Each shunt that is encountered with the approximate amount of blood that passes each shunt.
- Explain the functions of the amnionic fluid and define the following:
Reading Assignment: Whitaker, pp. 3-10; 16-24
The High Risk Pregnancy: Assessment of Fetal Growth and Development
- Given an approximate history, determine wheter a pregnancy is high risk.
- Discuss the effects of maternal age on pergancy risk.
- Describe the features of toxemia of pregnancy.
- List the conditions related to uteroplacental insufficiency.
- Describe the possible results of uteroplacental insufficiency.
- Explain the possible effects fo maternal diabetes on fetal development in genereal and on lung maturation in particular.
- Define Teratogenensis. Describe the effects of the abuse of such teratogens as tobacco, marijuana, cocaine and alchohol.
- Describe the possible effects fo maternal infection with rubella, toxoplasmosis, herpes,cytomegalovisis, and syphilis on the fetus.
- List and describe maternal anatomic abnormalities which may increase fetal risk.
- Describe how ultrasonography is used to assess fetal status.
Define amniocentesis and describe the role of each of the following
- L/S ratio
- Determination of alpha-fetoprotein
- Creatinine level
- identification of meconium staining
cytologic examination of cells
List and describe the different methods of measuring fetal heart rates and describe the cause and characteristics of the following:
- baseline heart rate
- beat-to-beat variability
Explain how fetal scalp pH is used to assess fetal asphyxia
- List and describe the five methocs used to estimate the date of delivery.
- Compare and contrast the contraction stress test with the non-stress test. Describe how each is performed and the advantages and disadvantages.
- Describe the use of acoustic stimulation and fetal movements as methods of assessing fetal well being.
- Describe the six tests used in the biophysical profile.
- Discuss the implications of meconium stained amnionic fluid in assessing fetal well being.
handout from Koff Neonatal &Pediatric Respiratory Care, Chapter 2*pp 30-47,
Labor, Delivery, and Physiologic Changes After Birth
-Stages of Normal Labor and Delivery
-Abnormal Labor and Delivery
-Adaptation to Extrauterine Life
Reading Assignment: Whitaker pp 56-76 Assorted handout materials.
LABOR & DELIVERY...........................................................................
- Describe the basic process of cervical dilatation and effacement. Identify the most common presentation.
- Define station and how it is expressed. Describe the sequence of events that lead to the descent and delivery of the fetus.
Define tocolysis and describe the various methods used to achieve tocolysis.
Define dystocia and describe the three etiological factors that cause it.
Describe each of the following types of presentation
- complete breech
- incomplete or footling breech.
- frank breech
- face presentation
- transverse lie
- prolapse of the umbilical cord and occult cord compression.
- Identify and describe the three types of placenta previal
- Describe the three categories of abruptio placentae and discuss treatment.
- Discuss the issues and risks associated with premature rupture of membranes (PROM)
- List the indications for Cesarean birth
- Discuss the problems of multiple gestation in high risk pregnancies.
- Explain what occurs in discordant and parabiotic twinning.
- List the factors that are responsible for the first breath
- Describe the importance of overcoming surface forces in adapting to extrauterine life.
Identify and describe factors that cause the change from fetal to the adult curciulation
Define hysteresis and describe and justify the shape of a normal hysteresis curve. Explain how a decreased pulmonary surfactant would affect the hysteresis curve.
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.
- Explain what is meant by time constants and the consequences of decreased expiratory time.
- Explain the effecte of decresaed compliance and increased airway resistance on tidal volume and respiratory rate in the newborn.
- Describe the differences between the adult and the newborn infant with regard to ventilation/perfusion ratio, diffusing capacity, and hemoglobin type.
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.
Week 4Respiratory Distress Syndrome
Surfactant Endogenous and Exogenous
Whitaker pp 10-15 Surface forces and the role of surfactant pp 170-175, 347-357 Respiratory Distress Syndrome
Koff Handout (from 1st class meeting ) pp 5-8
- 1. Define surface tension and describe the following:
Discuss the role of surfactant in pulmonary physiology
How it is developed
- Laplaces law
- application to alveolar mechanics.
- Identify the major componants of pulmonary surfactant and explain their function
Discuss the risk factors associated with the development of respiratory distress syndrome (RDS).
- List and describe the six abnormalities typically associated with RDS
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.
- Outline the clinical features of RDS and describe the usual clinical course.
Given a case description of a patient with typical but severe care of RDS, identify key steps in the proper treatment and management.
List the disorders which frequently accompany RDS or are complications of treatment
Describe the essential features foan effective exogenous surfactant
Describe the four types of exogenous surfactant.
Respiratory Disease in the Neonate
-Transient Tachypnea of the Newborn
Reading Assignment: Whitaker. pp 366-370; 444-445; 376-377
- 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.
- Describe the typical presentation and progression of TTN.
- Explain how TTN is diagnosed. Describe the typical chest x-ray findings.
- Given a typical TTN case, discuss how the patient should be managed.
- 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.
Identify the most common causative organism for neonatal pneumonia. Identify the complications that occur with this pneumonia. Identify other transplacental and perinatally acquired organisms.
- Identify causative organisms for late onset pneumonia. Discuss the ways in which pathogenbs are transmitted.
- Describe the clinical presentation,the most frequently encountered clinical issues,the typical x- ray findings, and the general management of the neonate with pneumonia.
- Identify the conditions which predispose a neonate to the meconium aspiration syndroome (MAS). Describe the meconium material.
- Discuss the do's and don'ts for the delivery room management of the meconium stained infant.
- 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.
Week 6Complications of Prematurity
Reading Assignment: Whitaker, pp. 357-366; pp.265-267
- Define retinopathy of prematuriy (ROP) and explain in general terms the nature of this disease. Identify the risk factors for developing ROP.
- Describe the process by which ROP develops. Describe the five stages of ROP. Identify the ways in which the disease is treated.
- 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
Summarize the physiological reasons by which intracranial and intraventricular hemorrhages develop. List the contributory factors of intraventricular hemorrhage.
- Outline the clinical signs that may be present in the neonate who is developing and intraventricular hemorrhage (IVH).
- Explain how long-lasting complications from IVH are managed. Explain how the condition known as posthemorrhagic hydrocephalus (PHH) develops and how it is treated.
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.
- Describe the pathophysioloy of NEC and the treatment.
Additional Issues in Prematurity
-Air Leak Syndromes
Whitaker, pp. 176-181; pp. 262-268
List the types of air leak syndromes that occur frequently in the neonate. Explain the pathophysiology of each of the types.
- Identify the two types fo pulmonary interstitial emphysema (PIE). Explain how PIE develops and how it can be prevented or minimized. Describe the pathophysiology.
- Explain ways in which pneumothorax can develop. Discuss the difference between spontaneous pneumothorax and tension pneumothorax.
Discuss how pneumothorax can be diagnosed. Decribe the signs and symptoms. Explain how the transilluminator is used to diagnose pneumothorax.
Describe the emergency and non-emergency treatment of pneumothorax.
Differentiate pneumomediastinum from pneumothorax and discuss the treatment.
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.
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
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.
Disorders in the Newborn
-Congenital Anomalies Involving the Airway
-Infectious Disease Involving the Airway
Explain what is meant by apnea fo prematurity. List the three types of apnea.
Describe the mechanism to which the cause of apnea of prematurity is attributed.
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.
- Describe the type of child who has obstructive sleep apnea. Discuss some of the major treatments for this problem.
Define sudden infant death sydrome (SIDS) and identify the age group affected. Explain how a diagnosis is made.
- 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 "prone position" theory.
- Explain what is meant by an ALTE and how a patient affected by SIDS can become an intensive care admission.
Discuss the types of congenital tracheoesophageal fistulas. Explain what is meant by esophageal atresia. Describe the signs seen in the newborn that may lead to a suspicion TEF. Explain how the infant with TEF should be positioned.
Discuss the signs of choanal atresia and explain how the affected infant should be managed before surgical repair.
Identify the major congenital anomalies which produce airway obstruction.
Explain how stridor is produced. Explain how the character of stridor differs with partial obstructions at different locations in the airways.
In the child with laryngomalacia describe the structural abnormalities and discuss the prognosis and management.
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.
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.
Identify the airway structures that are affected by epiglottitis. Explain how this disease is diagnosed. Explain how an airway emergency can arise from this problem. Discuss the cause, presentation, and treatment of epiglottitis.
Distinguish between croup and epiglottitis. Identify the three types of croup.
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.
Handout from Koff, pp 198-184
Whitaker, pp. 377-382; 400-403; 182-189; 444-452
Surgical Disorders in the Newborn and Child
1. For each of the following pulmonary lesions, explain exactly what they are and discuss the potential causes, potential complications, and treatment issues:
- a) congenital adenomatoid malformation (CAM)
- b) bronchogenic cysts
- c) congenital lobar emphysema
- d) sequestration
- e) congenital diaphragmatic hernia (CDH)
- Describe congenital diapharagmetic hernian and define the paradigm. Explain how an to what degree ventilation is compromised in CDH.
- Discuss the diagnosis and delivery room management of CDH.
Describe the ventilation strategies used in treating CDH.
- Describe additional treatment measures for CDH in addition to or beyond mechanical ventilation.
Reading Assignment: Whitaker, pp. 178-179; 400-403
Additional Disorders in the Newborn and Child
-Reye's Syndrome-Cystic Fibrosis
Distinguish between the definitions of gastroschisis and omphalocele. Discuss how both of these problems are thought to develop.
- 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.
- Classify neurolmuscular diseases into the neuronopathies, neuropathies, myopathies, and myasthenic syndromes. Explain what is meant by the term hypotonia. Explain the difference in how a child with a neuromuscular disease would present as compared to one with a primary brain disease.
- Explain what constitutes Wernig-Hoffman disease, discuss the two types, and discuss the treatment and prognosis. Discuss the problem of spinal deformities that occur in many neuromuscular diseases.
- Classify the two types of neuropathies. List and describe the pathology of the three types of demyelinating neuropathies. Discuss the management of affected patients and the progression of each type.
- Discuss the types of myasthenic syndromes, explaining the mechanism by which muscular weakness or paralysis occurs. Outline the treatments for these syndromes.
- Discuss the commonly encountered myopathies. identify the most common, describe its usual progression, and outline the treatment goals. Discuss options for assisted ventilatory support.
- Define Reye's syndrome, describe the usual progression, and identify the key elements of treatment.
- 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.
- Identify the infectious organisms that affect CF patients and explain why infection is problematic in advancing the disease.
- 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.
Reading Assignment: Whitaker, pp.436-438; 447-453; 431-436
Cardiac Anomalies: Defects that Increase 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
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