A neonate of 30 weeks' gestation shows signs of respiratory ...

[audragclark]

A neonate of 30 weeks' gestation shows signs of respiratory distress after delivery, including grunting, nasal flaring, and cyanosis.
 
  The baby is placed on nasal CPAP at 6 cm H2O with an FIO2 of 0.6. The grunting and nasal flar-ing are alleviated, and the ABG results on these settings are: pH = 7.20, PaCO2 = 64 mm Hg, PaO2 = 48 mm Hg, SaO2 = 70, HCO3 = 21 mEq/L. The respiratory therapist should recommend which of the following?
  a. Increase the CPAP to 8 cm H2O and the FIO2 to 0.7.
  b. Switch to nasal IMV, an inspiratory pres-sure of 18 cm H2O, PEEP of 4 cm H2O, and an FIO2 of 0.8.
  c. Continue with the current settings and monitor the patient closely.
  d. Intubate and use PC-IMV, an inspiratory pressure of 16 cm H2O, PEEP of 5 cm H2O, and an FIO2 of 0.8.

Question 2

A newborn of 32 weeks' gestation is currently receiving nasal CPAP. The respiratory therapist recently increased the CPAP level from 8 to 10 cm H2O; the FIO2 is 0.6. On the new setting, the PaO2 is 52 mm Hg and the PaCO2 increased from 48 to 55 mm Hg.
 
  The most likely cause of this is which of the following?
  a. Barotrauma
  b. Alveolar overdistention
  c. Ventilator-induced lung injury
  d. Increased pulmonary vascular resistance

[dpost18]

Answer to Question 1

ANS: D
This neonate meets the requirements for invasive mechanical ventilation because of continued signs of respiratory distress: respiratory acidosis and a PaO2 of 48 mm Hg with an FIO2 of 0.6. Remaining in CPAP would not address the respiratory acidosis or the hypoxemia. Increasing the CPAP level and the FIO2 would not address the respiratory acidosis. This patient is showing se-vere ventilatory impairment (pH <7.25, PaCO2 >6 mm Hg) and refractory hypoxemia (PaO2 <50 mm hg on an fio2>0.6); therefore, the patient should not be placed on NIPPV.

Answer to Question 2

ANS: B
The rise in CO2 after the increase in the CPAP level is most likely due to pulmonary overdisten-tion, which leads to increased work of breathing. The increased WOB causes CO2 retention.