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NeonatalPediatric Assessment
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Epiglottis is proportionately larger, less flexible, and omega ... Effort labored vs unlabored. Neonatal PFT's. Compliance and Resistance. Classic method ... – PowerPoint PPT presentation
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Title: NeonatalPediatric Assessment
1
Neonatal/Pediatric Assessment
- Chapter 5
2
Anatomical/Physiological differences
- Infant tongue proportionately larger than adult
- Large amount of lymphoid tissue in the
pharynxgreater risk of obstruction - Epiglottis is proportionately larger, less
flexible, and omega shaped and lies more
horizontally - Larynx is higher in the neck
- Narrowest part of larynx is cricoid ring (glottis
in the adult)means you could get tube through
vocal cords but not be able to pass it into the
lungs - Tracheal diameter is smaller (4cm vs 16 cm)
3
More differences
- Ribs/sternum mostly cartilageoffer little
support and stability to chest - Heart is large in proportion to the thorax since
thorax has little stability, its difficult to
increase Vt by chest expansionlarge abdominal
contents push up against the diaphragm all this
results in low pulmonary reserve - Obligatory nose breathersnasal congestion
increases WOB and resistance
4
Metabolism
- Infants have higher metabolism than adults so
oxygen requirements are high - Dont respond to meds in a predicatable way
because of the variation in metabolism
5
Other factors
- Large skin surface for body weightthis increases
heat loss - 80 of total body weight is watermakes fluid
balance precarious and difficult to
maintainbabies will become dehydrated very easily
6
Gestational Age Assessment
- Used to be based on weight, but all fetuses dont
grow equally - 2 scales in use
- Dubowitz looks at 11 physical and 10
neurological signs to determine ageusually
accurate to within 2 weeks - Ballard looks at 6 physical and 6 neurologic
signsaccuracy is comparable to Dubowitz and its
easier to do
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Physical Exam to Determine Age
- Vernix white, cream cheese stuffappears about
20 wks and starts to disappear at 36 wksusually
gone by term - Skin maturity the younger the baby, the more
transparent and sticky the skin - Lanugo fine hair that appears at 26 wks and
starts to disappear at 32 wksusually gone by
term - Ear recoil the youner the baby, the easier to
fold the ear and it will stay folded overrecoil
is normal at term - Breast tissue no breast tissue at 25 wksbreast
bud at 30 wks - Genitalia the older the baby, the more defined
the genitalia - Sole creases the older the baby, the more
creased the bottom of the foot
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Physical Exam of the Neonate
- Why do it?
- Determines physical defects
- Determines if the change to extrauterine life has
occurred - Quiet Exam when baby is unstressed
- Color should be pinkacrocyanosis commonyellow
jaundicegreen meconium - Lanugo present or absent
- Activity assess tone and movement of
extremities - Head check size
11
PE, cont
- Respiratory rate 30-60 is normalperiodic
breathing vs apnea - Signs of respiratory distress grunting,
retracting, flaringSilverman Index - Hands-On Exam (warm them first!)
- Inspect headpalpate fontanelle
- Bulging increased ICP
- Depressed dehydration
- Check ears, breast tissue, genitals, and feet to
determine gestational age
12
PE/Hands-On, cont
- Listen to heart murmurs common with septal
heart defects, patent FO, patent ductus
arteriosus (PDA) - Palpate pulses and compareweak could be
hypotension/low COnormal brachial with decreased
femoral coarctation of aorta or PDA - Measure BP normal term is 80/50
- Palpate abdomen scaphoid diaphragmatic hernia
- Check umbilical stump only 2 vessels associated
with urinary problems - Check temp neutral thermal temp 36.2 37.3
13
Neurological Exam
- Rooting stroke corner of mouthbaby should turn
its head towards the stroke - Suck put finger or pacifier in mouthbaby
should suck - Grasp place finger in palmbaby should grasp it
- Head control pull to sitting positionhead
shouldnt be limp - Moro let down to a lying position and just
before head touches the bed, let goarms should
fly up and out and knees pull in and up
14
Peds Patients
- Start with a thorough history
- Acute or chronic problem?
- Recurrent infections?
- Has this happened before? What did they do?
- Does this run in the family?
- What is the cough like? Barking? Productive?
- Any history of wheezing?
- Any chest pain?
- What does sputum look like? (white, yellow,
green, green/smelly, brown, red, mucoid,
purulent, mucopurulent) - Growth pattern?
- Environment? Smokers? Pets?
15
Examining the Peds Patient
- Try to localize the disease
- CXR
- Auscultation
- Percussion
- Tracheal position
- Analyze gas exchange
- ABG
- Sat
- Signs of hypercarbia/hypoxia
- Look at respirations
- Rate should be 12-20 by age 12
- Infant 30-60
- 1 year old trouble if gt40
- 5 year old trouble if gt35
- Depth hyperpnea vs hypopnea
- Effort labored vs unlabored
16
Neonatal PFTs
- Compliance and Resistance
- Classic method
- Uses an esophageal balloon to measure pleural
pressure - A face mask with a pneumotach measures flow
- An airway pressure manometer is attached to the
mask - To measure compliance, need to know the Vt (get
from pneumotach), proximal airway pressure (get
from mask), and pleural pressure (from esophageal
balloon) - Subtract pleural pressure from proximal pressure
and divide into the Vt (C V/P) - Things that interfere with the esophageal ballon
make this method inaccurate, such as cardiac
oscillations or resp effort by the baby
17
Neonatal PFTs, cont
- Occlusion Technique
- Measures alveolar pressure at a known lung volume
- Obtain alveolar pressure by occluding the airway
after the inspiration of a known Vt hey, this is
just like plateau pressure!! - Divide the plateau pressure into the Vt
- Doesnt work if the patient is making insp.
efforts while you are occluding
18
Neonatal PFTs, cont
- Expiratory flow rates
- Hard to get accurate flow measurements on babies
- Can squeeze the thorax to get a forced expiration
but flow depends on force of squeeze - Can also apply suction to the airways and measure
flow it generates - Really not done routinely
- FRC
- Helium dilution
- N washout
- Plethysmography
- Crying VC measures VC during crying
19
Pediatric PFTs
- Performance
- Accuracy dependent on cooperation of child
- Same routine as for adults with a few twists
- Equipment
- Must be accurate at low volumes and flows
- May need to use a mask rather than a mp
- May need parent to participate in the testing
- Practitioner
- Needs to be child-friendly
- Needs to know what they are doing, because you
might only get one shot - Interpretation
- 3 tests within 10 of each other is required for
validity - Use equations because normals charts dont go
that young
20
Peds PFTs, cont
- Total lung volume
- N2 washout or He dilution will work if there are
not airway obstructions (eg-asthma, foreign
body) - Must use smaller volume equip and tubing since
FRC is smaller - Use a low deadspace valve
- Can also use plethysmography
- For infants, they make a cabinet that you can lay
the baby in with their mouth fitted against the
opening - OR, parent can hold child on their lapthey have
to hold their breath while you are doing the
testing and you have to correct things for the
volume of the adult in the box - DLCO not usually done b/c peds patients dont
usually have diffusion diseases
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