1. Bingham, Raymond J. RNC

Article Content

The low winter sun filtered through the drawn shades, waking me. I looked at the clock and cursed. It wasn't even noon. I was coming off my first night of work on the neonatal intensive care unit (NICU), and with another busy shift coming up I needed more than just a few hours of sleep.


I rolled out of bed and looked out the window. Snow still covered the ground, and the barren trees shivered in the stiff wind. Hoping the chill would shake off my cobwebs, I bundled up my six-month-old daughter Rosalyn for a walk in the woods, to take the air.


When I started in the NICU I was amazed at what newborns had to go through to stay alive. While in utero, the fetus floats in a warm, protected, fluid environment. With the mother's blood bringing oxygen and nutrients and taking away wastes, it has little to do but grow and develop. Then everything changes as it is squeezed out into a cold, harsh, dry world, and the umbilical cord is cut. Now on its own, the most vital task of the newborn is to take a breath of air.


The quiet expanse of the woods contrasted with the NICU, where machines hummed, monitors beeped, people talked, objects clattered to the floor, and sometimes babies even cried. As Rosalyn and I walked, I filled my lungs, letting the crisp air wash away my tensions.


Breathing becomes so automatic, we rarely think about it. Our diaphragm contracts and our ribs rise, generating a slight negative pressure within the chest that draws fresh air down the trachea to the main bronchi, into the bronchioles, finally reaching the alveoli. Then, the diaphragm relaxes, the ribs fall, and air is pushed out again. Inhale, exhale.


Breathing can be a struggle even for a full-term newborn. At birth, the unused airways are collapsed, the lungs filled with fluid from the womb. The newborn's first breath must expand these airways and push out this fluid. The hardest breath you ever took was that first breath of your life. For a premature baby with undeveloped lungs, breathing is an immediate battle.


As I walked with Rosalyn, I recalled the birth of a 1-lb., 25-week newborn I had attended during the night. After carrying him immediately to the warming bed, the neonatal NP and I assessed his signs of life and observed his first breaths. When his diaphragm pulled down it pushed out his abdomen, while the chest wall collapsed, the skin between his ribs retracted inward, and his nostrils flared. Listening to his chest, I heard only a tiny wisp of air moving. As he exhaled, he forced the air through partially closed vocal cords and glottis, generating back pressure to keep his airways open while producing an audible grunt. Then, as rapidly as he could muster the strength, he took another breath.


The parents named their little boy Ken. Essentially still a fetus, he had stiff lungs unready for use, and his feeble efforts were wrenching to watch.


It is in the alveoli that air comes in contact with the fluid of the blood, making them susceptible to the collapsing force of surface tension. Ken fought, with each breath, to reopen the tiny sacs. The neonatal NP intubated him, and we hooked him up to a ventilator.


Cells in the lining of mature alveoli secrete a phospholipid substance, called surfactant, which coats the inner surface to negate surface tension. This allows the alveoli to remain expanded, easing the work of breathing. A developing fetus doesn't make enough surfactant on its own until around 32 to 34 weeks of gestation, but modern medicine has developed a replacement. The neonatal NP dripped this white, slippery fluid down the endotracheal tube into his lungs. The effects were almost immediate, and we were able to begin weaning Ken from the ventilator.


As I walked through those winter-barren woods, I was aware of how my own lungs craved the crisp air, and I began to wonder. Maybe what I needed to do was to bundle up my little patient, bring him to these woods and let him take in this magical air.


I laughed off this thought. Wise beyond her months, Rosalyn laughed too.


Still, I continued to walk, keeping that air within me. I carried it to Ken that night. With this air, and with luck, he may soon leave our unit. Then, like Rosalyn and me, he can take the air for himself.