Walsh: Perinatal and Pediatric Respiratory Care, 3rd Edition

Chapter 28: Surgical Disorders in Childhood that Affect Respiratory Care

Answers to Assessment Questions and Clinical Scenarios

1.	B
Rationale: If an 8 French (8F) catheter fails to pass through the nose into the oropharynx, choanal atresia should be suspected. However, in this scenario, the neonate must be stabilized by immediately inserting an oral airway.
Then verify the diagnosis and assess for other anomalies associated with choanal atresia (CHARGE: coloboma, heart anomalies, choanal atresia, retardation of growth and development, and genital and ear anomalies). The ultimate management is surgical correction.
2.	B
Rationale: Chronic upper airway obstruction from anatomic malformations results in chronic hypoxia, CO2 retention, related sequelae such as cor pulmonale, and pulmonary hypertension; all of which have a high mortality rate. Other complications include failure to thrive, malnutrition, aspiration, and pneumonia.
3.	B
Rationale: The most common combination of lesions is esophageal atresia associated with a distal tracheoesophageal fistula (see Figure 28-1. Greater than 85% of patients will present with this form of the anomaly, which results in a blind-ending upper esophageal pouch of variable length associated with a fistula from the lower trachea or mainstem bronchi that leads into the distal esophagus.
4.	D
Rationale: Drooling is the first symptom in the majority of newborns with esophageal atresia. The first feedings result in choking, coughing, and episodes of cyanosis. The respiratory distress may be severe and progressive, which should prompt an immediate work-up for esophageal atresia. If esophageal atresia is suspected, the VACTERL syndrome (vertebral, anal, cardiac, tracheal, esophageal, renal, limb) anomalies may be present. Also, while in utero, the fetus cannot swallow amniotic fluid, resulting in polyhydramnios.
5.	A
Rationale: The lung tissue is hypoplastic, including the pulmonary vasculature, even on the contralateral side. Histologic studies demonstrate increased musculature in the media of the arterioles, worsening hypertension. After birth hypoxia, hypercapnia, and acidosis develop, causing constriction of the arterioles. This constriction exacerbates persistent pulmonary hypertension and persistent fetal circulation.
Surgical repair does not reverse the complications associated with CDH.
6.	D
Rationale: Intubation is not the first option at this time. Before bag–mask ventilation can be performed something must be done to vent gas from the stomach and minimize air accumulation in the thoracic intestines. Do this even before oxygenation, because crying and gasping cause air swallowing and dilation of the loops of intestines in the thorax.
7.	B
Rationale: High rates and low pressures are best achieved by high-frequency oscillation. In addition, any hyperventilation may help lower pulmonary vascular resistance.
8.	B
Rationale: Compliance is reduced as the contents are pressed into the abdomen, along with the swelling that occurs postoperatively. Reduced compliance results in a decreased time constant and higher ventilating pressures.
9.	C
Rationale: Omphalocele is a midline defect covered by peritoneal tissue and an important observation when making the differential diagnosis and recognizing the possibilities of other anomalies, especially cardiac.
Gastroschisis is the only true full-thickness defect, and it is not associated with other anomalies.
10.	A
Rationale: Although these lung bud anomalies have very different histopathologies, there are patterns in clinical presentation common to all. The presentation seems to follow two distinct patterns: (1) the condition becomes obvious in the early newborn period and is manifested by respiratory distress; or (2) the condition occurs later in childhood and is characterized by repeated infections.