NEONATAL RESPIRATORY CARE (LAB)

LECTURE 1: DEVELOPMENT OF CARDIOPULMONARY SYSTEM

PROF: MARK KELWIN C. DAGUIAO, RTRP, MPH
2ND SEMESTER A.Y. 2022 – 2023
PLACENTAL GAS EXCHANGE UMBILICAL CORD - lifeline between mother and
Placenta fetus
➢ 6 to 8 inches in diameter, 1 inch thick and ➢ Wharton's Jelly → tough, gelatinous
weighs approximately 1 pound
material. -insulates and protects the
➢ appears as a reddish-brown disk → fully
umbilical vessel
developed
➢ Primary center for gas exchange Amnion
➢ Provides oxygen and nutrients ➢ sac that surrounds the growing fetus and
➢ Removes waste products from the baby’s contains the amniotic fluid
blood ➢ arises from the trophoblast → 7th day of
➢ Low resistance circulatory system → blood gestation
can easily flow ➢ begins as small vesicle and develops into a
➢ consists of about 15 to 20 segments called
sac, which covers the dorsal surface of the
cotyledons
*Cotyledons - composed of fetal vessels, embryo
chorionic villi, and intervillous spaces. ➢ as gestation progresses it enlarges and
surrounds the embryo
>> Deoxygenated blood from the fetus → two
umbilical arteries → placenta Amniotic Fluid
>> Once in the placenta, the umbilical arteries ➢ Fluid fills this newly developed sac, called
branch and supply each cotyledon. amniotic fluid
➢ amount of amniotic fluid is greatest at
• Oxygen transfers from the maternal to fetal
about 84 weeks gestation and averages
blood because of the:
around 800mL
1. maternal-Fetal gradient
➢ amount slowly diminishes to reach around
2. high Hb concentration in the fetal blood
600 mL at full term
compared with that of maternal blood
➢ dynamic → Constantly being absorbed
3. greater affinity of fetal hemoglobin (HbF)
and replenished
for oxygen than of adult hemoglobin (Hb A)
Factors Affecting Gas Transfer Across Placenta Functions of Amniotic Fluid
• Diffusion limitation • Protection prom traumatic injury
• Shunts present in maternal and fetal • Thermoregulation
• Oxygen consumption within placenta • Facilitation of fetal movement
Phases of Lung Development
circulation
1. Embryonic – primitive development
• Uneven distribution of maternal blood flow
2. Pseudoglandular – conducting airways
• Uneven distribution of diffusing capacity to
3. Canalicular – respiratory portion and
blood flow
Fetal Blood Gas Values vascularization
4. Terminal (saccular and alveolar)
Average Average
→ well defined gas exchange.
Age 38 weeks Age 25 weeks
PHASE 1: EMBRYONIC STAGE
Umbilical Umbilical Umbilical Umbilical ➢ 1st 5 weeks of gestation
Artery Vein Artery Vein ➢ 26 days gestation - earliest formation of
pO2 26 32 28 43 the lung begin
➢ outpouching of foregut, lung bud,
pCO2 43 37 35 35 develops in the endoderm
pH 7.36 7.39 7.37 7.41 ➢ → continues to grow, divide and becomes
enveloped (R and L mainstem bronchi)
➢ 7th week → diaphragm is complete
➢ 32 to 37 days - primitive pulmonary arteries
and veins begin to appear

K. CALLUENG, K. CHAN, G. OQUIAS | RTRP2K24 | 1

 NEONATAL RESPIRATORY CARE (LAB)
LECTURE 1: DEVELOPMENT OF CARDIOPULMONARY SYSTEM
PROF: MARK KELWIN C. DAGUIAO, RTRP, MPH
2ND SEMESTER A.Y. 2022 – 2023

PHASE 2: PSEUDOGLANDULAR STAGE Components of Surfactant*

➢ 6 – 16 weeks 85% Phospholipids, 5% Neutral lipids, 10% Proteins
➢ Mucous glands begin to appear
➢ 7th weeks → ciliated cells appear Surface tension
➢ 10th weeks → submucosal glands appear ➢ result from the attractive forces
➢ Goblet cells appear between liquid molecules lining the
➢ 12th weeks → fetal breathing begins and alveoli at the air-liquid interface
mature breathing occurs after 30 weeks ➢ creates a collapsing pressure that is
➢ 16th weeks → prenatal formation of new
directly proportional to surface tension
bronchi is nearly complete
➢ Asymmetric dichotomous branching of and inversely proportional to alveolar
bronchial tree radius (LaPlace’s Law)
→ 4 to 25 generations at 16 weeks of P = 2T/r
gestation
PHASE 3: CANALICULAR STAGE where:
➢ 16 to 26 weeks P = collapsing pressure on alveolus (or
➢ 16th weeks → first identifiable components pressure required to keep alveolus
of the respiratory unit appear open) (dynes/cm²)
➢ Primitive lobules are formed at the T = surface tension (dynes/cm²)
beginning of the canalicular phase
r = radius of alveolus (cm)
➢ Alveolar capillary membrane begins to
develop
➢ Pulmonary acinar units are formed
• Type 1 cells
➢ Essential to the development of AC
membrane; line relatively large surface
of the alveolar surface
→ small perinuclear bodies with
cytoplasmic extensions
• Type 2 cells
➢ Larger and rounder
DIPALMITOYLPHOSPHATIDYLCHOLINE (DPPC)
→ contains lamellar bodies, which
surfactant storage sites ➢ begins to rise at 24th weeks
→ involved in surfactant production, ➢ responsible for reducing surface
storage, secretion, and reuse tension
➢ Epithelial cells at this point are capable PHOSPHATIDYLGLYCEROL AND OTHER ACIDIC
of producing fetal lung liquid PHOSPHOLIPIDS
SURFACTANT ➢ Speed absorption, that is the
➢ Substance found in the lungs movement of surfactant within the
➢ Produce by alveolar type II cells liquid lining to the air-liquid interface
➢ Lecithin – makes up the majority of
PROTEIN
surfactant
➢ SP-A → it is the most plentiful among
➢ 24th weeks – DPPC begins to rise
proteins in the surfactant
➢ By 35th weeks 2:1 ratio is present
→ it is hydrophilic, responsible in recycling
less than 1 is likely RDS is possible while greater than
of surfactant and it has immunologic
a ratio of 2 indicates lung maturity
properties
➢ reduce surface tension of the alveolus
➢ SP-B AND SP-C → hydrophobic proteins
➢ sheds water from the alveolar surface
and responsible for surfactant shaping so
➢ prevent alveolar surface tension – driven
that it fits receptor sites
collapse
➢ improves lung compliance
➢ reduces the work of breathing
➢ protects the alveolar surface
➢ pressure needed to distend on alveolus is
indirectly proportional to the surface
tension – Pierre Simo Laplace (LaPlace’s
law)

K. CALLUENG, K. CHAN, G. OQUIAS | RTRP2K24 | 2

 NEONATAL RESPIRATORY CARE (LAB)
LECTURE 1: DEVELOPMENT OF CARDIOPULMONARY SYSTEM
PROF: MARK KELWIN C. DAGUIAO, RTRP, MPH
2ND SEMESTER A.Y. 2022 – 2023
DEVELOPING CARDIAC STRUCTURE
CONDITION THAT AFFECTS THE PRODUCTION AND
MATURATION OF SURFACTANT Neonatal structure Corresponding Embryonic
Accelerated maturation Structure
• Chronic retroplacental bleeding (“chronic Inferior and Sinus Venosus
abruptio,” circumvallation) Superior Vena
• Prolonged rupture of fetal membranes (after Cava
28 weeks of pregnancy) Atria Dilation of Heart Tube
• Prolonged labor without asphyxia Septum Endocardial Cushion
• Placental insufficiency Left Ventricle Dilation of Heart Tube
• Sickle cell disease Right Ventricle Bulbus Cordis
• Smaller identical twins Pulmonary and Truncus Arteriosus
• Maternal diabetes mellitus
Aortic Artery
• Hyperthyroidism
Pulmonary Vein Outgrowth of Posterior
• Racial and Sex differences (female)
Wall of Left Atrium
Delayed maturation
• Maternal diabetes mellitus (poor balance, Fossa Ovalis Foramen Ovale
some White’s classes A, B, and C) Ligament Ductus Arteriosus/
• Hydrops fetalis Arteriosum/ Venosus
• Smaller of nonparabiotic identical twins Ligament Venosum
• Nonhypertensive chronic glomerulonephritis
• Conditions associated with shock (severe FETAL CIRCULATION
infection, severe asphyxia) FLOW CHART OF MOST OXYGENATED FETAL BLOOD
• Chronic oligohydramnios starting before 28 Placenta → Umbilical vein → Ductus venosus →
weeks Inferior vena cava → right atrium → foramen ovale
PHASE 4: TERMINAL STAGE → left atrium → left ventricle → aorta → developing
• Saccular Stage brain
o Interstitial tissue and saccular walls FLOW CHART OF LEAST-OXYGENATED FETAL BLOOD
become thinner
o Surfactant maturation
o Macrophages appear
o A-C membrane increase in size
o 28th weeks → carotid body
chemoreceptor → mature enough
to function
o Alveolar ducts opened into terminal
saccules
• Alveolar Stage
o 36th weeks to term
o Alveolar type I cells → become thin
and elongated
o Significant number of alveoli have
developed
o Surfactant is present FIRST TRIMESTER
CARDIAC DEVELOMENT 21 DAYS Heart is fully formed
➢ 21 days→ “blood islands” or isolated cells 26 DAYS Lung buds appear
clusters known as Angiogenic clusters are 28 DAYS Mainstem bronchi appear
seen 32-37 DAYS Pulmonary arteries and primitive
➢ 3 to 8 weeks → heart develops pulmonary veins
➢ 4th week → heart start to beat 7 WEEKS - Diaphragm is complete
→ it twists and fold and eventually will form - Cilia in the upper airway
the 4 chambers 6-8 WEEKS Immature smooth muscle
➢ 5th week → heart takes the shape of adult 8 WEEKS Heart is fully functional,
heart complete with all chambers,
➢ Develop veins and arteries couple the valves, and blood vessels
heart to circulatory system 10 WEEKS Submucosal glands and goblet
➢ 4 chambers are formed with opening cells appear
between atria and ventricles

K. CALLUENG, K. CHAN, G. OQUIAS | RTRP2K24 | 3

 NEONATAL RESPIRATORY CARE (LAB)
LECTURE 1: DEVELOPMENT OF CARDIOPULMONARY SYSTEM
PROF: MARK KELWIN C. DAGUIAO, RTRP, MPH
2ND SEMESTER A.Y. 2022 – 2023
POTTER
SECOND TRIMESTER ➢ pulmonary hypoplasia
14 WEEKS Patter arteries is recognized on ➢ oligohydramnios
arteriogram ➢ twisted skin (wrinkled skin)
16 WEEKS - Prenatal formation of new ➢ twisted face (facial deformities)
bronchi is complete ➢ extremities (limb effects)
- Pre acinar arteries are ➢ renal agenesis
complete
- alveolar epithelium begins PLACENTAL AND UMBILICAL PROBLEMS
differentiating into type I and ➢ Create potential risk for developing fetus
type II cells and infants
24 WEEKS Surfactant begins to rise o Umbilical cord compression
o Maternal bleeding
THIRD TRIMESTER
What are the risk factors of Umbilical Cord
28 WEEKS Mature carotid body
Compression
chemoreceptor
NUCHAL CORDS (and birth injury)
28-36 WEEKS Interstitial tissue and
➢ A complication that occurs when the
saccule walls become
umbilical cords wrap around the fetus neck
thinner
➢ Can interrupt normal blood, nutrient, and
28 WEEKS TO TERM Surfactant production
oxygen exchange resulting in the baby
matures
sustaining serious injuries such as HIE and
36 WEEKS TO TERM Actual alveoli appear
cerebral palsy
FACTORS AFFECTING LUNG GROWTH
➢ Maternal Polyhydramnios
➢ Maternal Oligohydramnios
➢ Placental and Umbilical Problems
MATERNAL POLYGOHYDRAMNIOS
➢ Over 200mL
➢ Abnormally large amount of amniotic fluid
➢ Problem with swallowing mechanism
Causes:
✓ Central Nervous System (CNS)
malformations
✓ Hydrocephalus, microcephaly,
anencephaly, spina bifida,
o Orogastric malformations →
esophageal atresia, pyloric stenosis,
cleft palate
o Disorders → down syndrome,
congenital heart disease, infants of
diabetic mothers, and prematurity
✓ Major complications → risk of premature
rupture of the amniotic membranes
✓ Leads to possible prolapse of the umbilical
cord and premature delivery
MATERNAL OLIGOHYDRAMNIOS
➢ Scant or decreased amount of amniotic
fluid CORD PROLAPSE
➢ defect in the urinary system → renal ➢ Emergency umbilical cord complication
dysplasia agenesis as well as urethral ➢ Normally, the baby exits the mother before
stenosis are involved the umbilical cord. In an umbilical cord
➢ may lead to oligohydramnios tetrad prolapse, the umbilical cord comes out
o intrauterine growth retardation before the baby.
o potter-face (flat face) ➢ This can happen when the mother’s water
o limb malposition breaks before the baby has moved into the
o pulmonary hypoplasia birth canal

K. CALLUENG, K. CHAN, G. OQUIAS | RTRP2K24 | 4

 NEONATAL RESPIRATORY CARE (LAB)
LECTURE 1: DEVELOPMENT OF CARDIOPULMONARY SYSTEM
PROF: MARK KELWIN C. DAGUIAO, RTRP, MPH
2ND SEMESTER A.Y. 2022 – 2023
➢ Cord prolapse is an obstetrical emergency
because the cord is at high risk for
compression, blocking oxygen and blood
flow to the baby. In these cases, an
emergency C-section is often necessary
with recommendations stating that they
should occur less than 12 minutes form the
onset of signs of fetal distress.
TRUE KNOT
➢ There are the knots that form in the baby’s
umbilical cord.
➢ Occur 1 out of 200 pregnancy and cause
hypoxic ischemic encephalopathy (HIE)
and other birth injuries
➢ Are detectable via ultrasound and is
standard procedure to test for knots
prenatally when certain risk factors exist
PLACENTA PREVIA
➢ Under normal circumstance, the placenta
connects to the uterine wall far from the
uterine opening or else migrates out of the
wall as the pregnancy progresses. In
certain cases, the placenta may partially or
completely cover the cervix. This is called a
placenta previa. It can cause hemorrhagic
bleeding, HIE, and birth trauma
K. CALLUENG, K. CHAN, G. OQUIAS | RTRP2K24 | 5
PLACENTA ABRUPTION
➢ A complication in which the placenta
separates prematurity from the uterine wall.
When this happens, the baby stops
receiving adequate oxygen. Placental
abruption is a medical emergency and
can cause HIE, PVL, cerebral palsy, and
other injury/ injuries.
TERATOGENESIS
➢ Development of abnormal structures in an
embryo, resulting in a deformed fetus
➢ Cause: teratogens
MATERNAL ACTIVITIES THAT AFFECT FETUS
Cigarette - fetal hypoxia
Smoking - decreased nutrient delivery
- intrauterine growth retardation
Marijuana - increased prematurity
smoking - decreased birth weight
- congenital heart defects
Cocaine - decreased birth weight
use - increased prematurity
- congenital heart disease
Alcohol - increased likelihood of being small
for gestational age
- CNS disturbances
- increased likelihood of
microcephaly
- facial dysmorphia
- decreased fetal activity and
breathing
 NEONATAL RESPIRATORY CARE (LAB)
LECTURE 1: DEVELOPMENT OF CARDIOPULMONARY SYSTEM
PROF: MARK KELWIN C. DAGUIAO, RTRP, MPH
2ND SEMESTER A.Y. 2022 – 2023
Congenital Malformations Anatomical Difference Between Adults and
Anomaly Description Week Children
Tracheoesoph Connection between 4 Anatomical Presentation in Children
ageal fistula trachea and Features Anatomical Features
esophagus (composed with adults)
Choanal Closure of the posterior 6 Tongue Larger in relation to the oral
atresia nares cavity
Pulmonary Non-functioning area of 6 Tonsils, adenoids, Larger in size; large amount of
sequestrations lung that receives blood and pharyngeal lymphoid tissue in pharynx
supply from systemic lymphoid tissue
circulation Epiglottis Larger, less flexible, and
omega shaped; lies more
Congenital Sac present within 6 horizontally
bronchogenic bronchi Epiglottis and Angle between is more acute
cysts laryngeal opening
Cleft palate Fissure in root of mouth 7-12
connecting mouth and Glottis Higher in and more anterior
nose Cricoid ring Narrowest portion of the
airway
Diaphragmatic Protrusion of abdominal 8 Cricothyroid smaller virtually non-existent in
hernia contents into thoracic membrane children
cavity Trachea Shorter
Laryngeal web Tissue covering the 10 Airway Smaller in diameter
larynx Thoracic cage Ribs and sternum are mostly
Omphalocele Protrusion of abdominal 10 cartilage (infants); ribs lay
contents through more horizontally
opening in the navel diaphragm Main action for breathing in
Gastroschisis Protrusion of abdominal 10 infant
contents through Mainstem bronchi Right mainstem angle lower
opening in the Conducting Smaller in diameter
abdominal wall airways
Alveoli - fewer at birth, increase in
number during childhood
- no pores of Kohn
Heart Larger than adults
Lungs Elastic Less than adults
Recoil
Abdominal Proportionally larger and push
Contents up against the diaphragm

Chest Wall Higher compliance

K. CALLUENG, K. CHAN, G. OQUIAS | RTRP2K24 | 6

 NEONATAL RESPIRATORY CARE (LAB)
LECTURE 1: DEVELOPMENT OF CARDIOPULMONARY SYSTEM
PROF: MARK KELWIN C. DAGUIAO, RTRP, MPH
2ND SEMESTER A.Y. 2022 – 2023
CARDIOPULMONARY EVENTS AT BIRTH IN THE FETUS
Fetal lung fluid ✓ Alveoli filled with lung fluid
• Prior to birth, production stops and ✓ In utero, fetus dependent on placenta
absorption starts for gasexchange
• 1/3 of fluid is expelled by vaginal squeeze ✓ Pulmonary arterioles constricted
• Pulmonary lymphatics absorb remaining ✓ Pulmonary blood flow diminished
fluid ✓ Blood now diverted across ductus
• Removed by lymphatic system arteriosusand foramen ovale
Tactile and Thermal Stimuli Initiate 1st breath AT BIRTH
• Initial breath requires transpulmonary ✓ Fetal lung fluid leaves alveoli
pressures >40 cm H2O during 1st breath ✓ Lungs expand with air with baby's first
• Subsequent breaths require progressively breath
less pressure as lung volume increases LUNGS AND CIRCULATION
✓ Cesarean – absorb by pulmo ✓ Pulmonary arterioles dilate
✓ Type II ARDS – fluid retained ✓ Pulmonary blood flow increases Blood
Air In Lung Increases PO₂ And Ph, While PCO₂ oxygen levels rise
Decreases, which Results In: ✓ Ductus arteriosus constricts
✓ Blood flows through lungs to pick up
✓ Pulmonary vasodilation & decreased PVR
oxygen
✓ Ductus arteriosus constriction/closure
✓ Increased pulmonary blood flow NORMAL TRANSITION
At The Same Time, Placenta Removal Results The following major changes take place within
In: seconds after birth
✓ Fluid in alveoli absorbed and replaced by
✓ Sudden increase in SVR
air
Net Results: ✓ Umbilical arteries and vein constrict thus
✓ LAP> RAP, so foramen ovale closes increasing systemic blood pressure
✓ Transition to extrauterine circulation ✓ Blood vessels in lung relax,
complete increasing pulmonary blood flow
Functional Closure of the Ductus Arteriosus: CLOSURE OF:
occurs as a result: ✓ Umbilical arteries and umbilical veins
✓ exposed to an increase in PaO2 ✓ Ductus arteriosus and foramen ovale
✓ decrease in PVR- leading to the reduction
in blood pressure within the ductal lumen
✓ decrease in the local production of
prostaglandins
✓ reduction in the number of prostaglandins
receptors within the tissue of the ductus
arteriosus
✓ Increase PaO2 → close R.A.
✓ Decrease PVR → close D.A.
✓ Prostaglandins – open D.A.
✓ Decrease indomethacin → close D.A.
✓ Constriction of Ductus Arteriosus starts at
birth
➢ 20% closes- 24 hrs
➢ 80% closes- 48 hrs
➢ 100% closes- 96 hrs
✓ Constriction → 2 to 4 weeks of age –
anatomical closure is complete and blood
flow normalizes the adult pattern of
circulation
*All of the following cardiopulmonary events
happen at birth, except?*
Ductus arteriosus dilation
Pulmonary vasodilation
Ductus arteriosus constriction/closure
Increased pulmonary blood
K. CALLUENG, K. CHAN, G. OQUIAS | RTRP2K24 | 7
 NEONATAL RESPIRATORY CARE (LAB)
LECTURE 1: DEVELOPMENT OF CARDIOPULMONARY SYSTEM
PROF: MARK KELWIN C. DAGUIAO, RTRP, MPH
2ND SEMESTER A.Y. 2022 – 2023
TRIVIA

The 'Pigg-O-Stat' is the device radiologists

use to safely immobilize babies and young
children that can't sit still during an x-ray.

K. CALLUENG, K. CHAN, G. OQUIAS | RTRP2K24 | 8