Professional Documents
Culture Documents
CHAPTER 1
INTRODUCTION
1.1 Background
1.1.1. Premature Baby
A premature baby is one who is born too early, before 37 weeks. Premature
babies may have more health problems and may need to stay in the hospital
longer than babies born later. They also may have long-term health problems that
can affect their whole lives. About 1 in 10 babies is born prematurely each year in
the United States.
The earlier in pregnancy a baby is born, the more likely he is to have health
problems. Some premature babies have to spend time in a hospitals neonatal
intensive care unit (also called NICU). This is the part of a hospital that takes care
of sick newborns. But thanks to advances in medical care, even babies born very
prematurely are more likely to survive today than ever before.
Premature babies can have some health problems after birth. Health problems
that may affect premature babies include apnea, respiratory distress
syndrome(RDS), Intraventricular hemorrhage (IVH), Patent ductus arteriosus
(PDA), Necrotizing enterocolitis (NEC) and many more. But the most common
breathing problem in babies born before 34 weeks of pregnancy is the respiratory
distress syndrome. Babies with RDS dont have a protein called surfactant that
keeps small air sacs in the lungs from collapsing.
Babies with RDS have some condition to go home from the hospital, like:
Weighs at least 4 pounds.
Can keep warm on his own, without the help of an incubator. An incubator is
CHAPTER 2
LITERATURE REVIEW
2.1. Prematurity
2.1.1. Definition prematurity
Prematurity is a term for the broad category of neonates born at less than 37
weeks' gestation. Preterm birth is the leading cause of neonatal mortality and the
most common reason for antenatal hospitalization.For premature infants born
with a weight of less than 1000 g, the 3 primary causes of mortality are
respiratory failure, infection, and congenital malformation.
2.1.2 Sign and symptoms
Confirmation of gestational age is based on physical and neurologic
characteristics. The Ballard Scoring System remains the main tool clinicians use
after delivery to confirm gestational age by means of physical examination. The
major parts of the anatomy used in determining gestational age include the
following:
Genitalia
Trouble breathing
Low weight
Underdeveloped muscles
Problems
feeding
due
to
underdeveloped
sucking/swallowing
coordination
Transparent skin
2.1.3 Patophysiology
Infection and premature delivery
The action of micro-organisms results in the development of fetal and/or
maternal inflammatory response chorionamnioitis, funisitis
and
and
IV.)
leukomalacia,
intraventricular
necrous
haemorrhage
enterocolitis,
(IVH),
periventricular
bronchopulmonary
dysplasia,
Uteroplacental ischaemia
White blood cell (WBC) count: A high or low WBC count and numerous
immature neutrophil types may be found; an abnormal WBC count may
suggest subtle infection
Blood type and antibody testing (Coombs test): These studies are
performed to detect blood-group incompatibilities between the mother and
infant and to identify antibodies against fetal red blood cells (RBCs); such
incompatibilities increase the risk for jaundice and kernicterus
Imaging studies
Imaging studies are specific to the organ system affected. Chest radiography is
performed to assess lung parenchyma in newborns with respiratory distress.
Cranial ultrasonography is performed to detect occult intracranial hemorrhage in
ELBW newborns. Prematurity itself is not an indication for an imaging study.
Lumbar puncture
Lumbar puncture is performed in infants with positive blood cultures and in those
who have clinical signs of infection (presumed sepsis) and for whom a full course
of antibiotic coverage is planned.
2.1.5 Treatment
Management
Stabilization in the delivery room with prompt respiratory and thermal
management is crucial to the immediate and long-term outcome of premature
infants, particularly extremely premature infants.
Respiratory management
Thermoregulation
In the intensive care nursery, radiant warmers may be used to compensate for heat
loss in the premature infant. Incubators are more efficient than radiant warmers
10
Electrolytes should not be added until the infant is 24 hours of age, when
urine output is adequate
Infants who develop acute tubular necrosis (ATN) should be treated with
fluid restriction that equals insensible water loss plus urine output
comprising
cyanosis,grunting,
retractions
and
11
States
develop
RDS
each
rises
12
bradykinin,
angiotensin,adenosine,
serotonin,
prostaglandins,
13
14
Prematurity
Male gender
Familial predisposition
Perinatal asphasia
Cancasian race
Chorioamnonitis
15
by
tachypnea
(>60
breaths/min),
intercostal
and
Cyanosis
Apnea
Decreased urine output
Nasal flaring
Puffy or swollen arms and legs
Rapid breathing
Shallow breathing
16
2.2.8 Management
The goals of management of an infant with RDS are to (Halliday, 2010)
17
The three most important advances in prevention and treatment of RDS have
been:
a) antenatal glucocorticoids
b) continuous positive airway pressure (CPAP) and positiveendexpiratory pressure (PEEP)
c) surfactant replacement therapy. These havedramatically decreased
morbidity and mortality from RDS.
1. Antenatal glucocorticoids
Antenatal administration of corticosteroids that pass through the placenta to
the foetus (betamethasone 24 mg; or dexamethasone 24 mg; or 2 g.
hydrocortisone) has been shown to decrease the incidence of RDS. Best results
are obtained if more than 24 hours and less than 7 days have elapsed between
commencement of treatment and delivery.
2. Exogenous surfactant
It has been shown in multiple randomized controlled trials that the use of
exogenous surfactant in preterm infants improves oxygenation, decreases air
leaks, reduces mortality due to RDS, and decreases overall mortality.
A. Timing of surfactant administration:
Two approaches have been used for surfactant delivery which is prophylactic
and rescue treatment.
Prophylactic administration
Involves giving surfactant soon after birth, as soon as the infant has been
stabilized. The theoretical benefit of this approach is that replacement of
surfactant before RDS develops will avoid or ameliorate lung injury. Animal
studies have shown that the lung epithelium of very premature subjects can be
18
damaged within minutes of onset of ventilation. The damage can result in protein
leak which subsequently interferes with surfactant function.
Rescue administration
Involves giving surfactant to infants who have established RDS and require
mechanical ventilation and supplemental O2. The advantage of this approach is
that patients are not treated unnecessarily. Because surfactant currently can only
be given via an endotrachealtube, this would prevent intubation and mechanical
ventilation of infants who would do well without surfactant and avoid
unnecessary baro/volutrauma, adverse physiological effects of laryngoscopy, and
possible inadvertent hyperventilation. Past studies have shown greater reduction
in neonatal mortality with prophylactic administration versus rescue, especially in
infants greatest at risk for RDS (i.e., <27weeks GA). However, with the use of
nasal CPAP in VLBW infants and higher rates of antenatal steroid administration,
there exists controversy on the optimal timing of surfactant administration,
balancing the benefits of early surfactant administration with the advantages of
avoiding mechanical ventilation and volutrauma. The current approach to the
timing of surfactant therapy at UCSF is summarized in Table 1.
19
Infasurf 3mL/kg
Survanta 4 mL/kg
20
21
22
23
CHAPTER III
CASE REPORT
3.1 Objective
The objective of this paper is to report a case of a 1 hour old boy with a diagnosis
of premature birth and respiratory distress.
3.2 Case
Baby AD, a 1 hour old boy, with 1.33 kg of birth weight and 38 cm of body
height, was admitted in Perinatology Division on 20 th July at 6.30 AM with chief
complaint of premature birth.
24
:-
History of family
:-
:-
History of pregnancy
History of birth
History of feeding
Physical Examination:
25
Present status:
Sensorium : compos mentis
Head
:
Head : frontal within normal limit
Face : edema (-), icteric (+)
Eye : light reflex (+/+), isochoric pupil, palpebral
conjunctiva pale (-/-), icteric (-)
Ears
Neck
:
Lymph node enlargement (-), neck stiffness (-)
Thorax
:
Symmetrical fusiform, retraction (+) epigastrial,
icteric (-), areola barely visible, no breast tissue
HR: 150 bpm, regular, murmur (-/-)
RR: 56 bpm, regular, ronchi (-/-)
Abdomen :
Soepel, normal peristaltic, liver and spleen
unpalpable, icteric (-)
Extremities
:
adequate p/v, felt warm, CRT < 3, pitting oedema
(-/-), icteric (-)
Anogenital
26
: 1) Premature
2) Respiratory Distress ec DD/ - Neonatal Pneumonia
- Hyalin Membrane
Disease
Laboratory finding:
Complete blood analysis (July 20th 2016 / 0932WIB)
Test
Hemoglobin
Erythrocyte
Leucocyte
Thrombocyte
Hematocrite
Eosinophil
Basophil
Neutrophil
Lymphocyte
Monocyte
Neutrophil absolute
Lymphocyte absolute
Monocyte absolute
Eosinophil absolute
Basophil absolute
MCV
MCH
Result
17.2
4.73
23.3
391
50
0.30
0.70
72.80
13.70
12.50
16.97
3.19
2.92
0.07
0.16
106
36.4
Unit
g/dL
106/L
103/L
103/L
%
%
%
%
%
%
103/L
103/L
103/L
103/L
103/L
fL
Pg
References
17 22
4.50 6.50
10 30
150 450
31 59
13
0.00-1.00
50 70
20 40
28
5.5-18.3
2.8-9.3
0.5-1.7
0.02-0.70
0.1-0.2
80-97
26.5-33.5
27
MCHC
Procalcitonin
34.4
g/dL
31.5 -36
0.43
ng/ml
< 0.05
Therapy :
4cc/ 5hour
GIR: 7,3
kg/kgBW/minute (D8%)
Aminosteril 6% 2gr/kgBW/day = 2,8 gr/day = 47cc/day =
1,9cc/hour/iv
o Enteral: Fasting (24 hours)
Ceftazidine injection 65mg/12 hour/iv (Day 1)
Gentamicin injection 6,5mg/36 hour/iv (Day 1)
28
FOLLOW UP
CNS: stable
Sensorium: CM Temp: 36.9C
Head: Frontal within normal limit
Eyes: Light reflex (+/+), isochoric pupil, diameter 2mm/2mm,
Pale conjunctiva palpebral inferior: (-)
CVS: stable
HR: 145 bpm, regular without murmur
Pulse: 145 bpm, regular, p/v sufficient,
Warm acral, CRT <3
Respiratory system: unstable
Nasal CPAP with FiO2 21% PEEP 6,
Flow 8 litre per minute, regular without ronchi
Metabolic system: unstable
Blood glucose (20/7): 65mg/dL
Infectious : unstable
Fever (-) Temp: 36.9 C
Leucocyte (20/7) : 23 310 PCT: 0.43
Hematologic : unstable
Hb/Ht/T: 17.2/50/391 000
IT Ratio: 0.16 CRP: <0.7
Musculoskeletel: stable
29
CNS: stable
Sensorium: CM Temp: 37.2C
Head: Frontal within normal limit
Eyes: Light reflex (+/+), isochoric pupil, diameter 2mm/2mm,
Pale conjunctiva palpebral inferior: (-)
CVS: stable
HR: 140 bpm, regular without murmur
Pulse: 140 bpm, regular, p/v sufficient,
Warm acral, CRT <3
Respiratory system: unstable
Nasal CPAP with FiO2 21% PEEP 6,
Flow 8 litre per minute, regular without ronchi
Metabolic system: unstable
Blood glucose (20/7): 65mg/dL
Infectious : unstable
Fever (-) Temp: 37.2 C
Leucocyte (20/7) : 23 310 PCT: 0.43
Hematologic : unstable
Hb/Ht/T: 17.2/50/391 000
IT Ratio: 0.16 CRP: <0.7
Musculoskeletel: stable
30
CNS: stable
Sensorium: CM Temp: 37C
Head: Frontal within normal limit
Eyes: Light reflex (+/+), isochoric pupil, diameter 2mm/2mm,
Pale conjunctiva palpebral inferior: (-)
CVS: stable
HR: 144 bpm, regular without murmur
Pulse: 144 bpm, regular, p/v sufficient,
Warm acral, CRT <3
Respiratory system: unstable
Nasal CPAP with FiO2 21% PEEP 6,
Flow 8 litre per minute, regular without ronchi
48 bpm
Metabolic system: unstable
Blood glucose (20/7): 65mg/dL
Infectious : unstable
Fever (-) Temp: 37C
Leucocyte (20/7) : 23 310 PCT: 0.43
Hematologic : unstable
Hb/Ht/T: 17.2/50/391 000
IT Ratio: 0.16 CRP: <0.7
Musculoskeletel: stable
1. Respiratory distress ec dd Hyaline membrane disease
Neonatal pneumonia
2. Low Birth Weight
3. Premature neonate
4. Suspect sepsis
31
CNS: stable
Sensorium: CM Temp: 37C
Head: Frontal within normal limit
Eyes: Light reflex (+/+), isochoric pupil, diameter 2mm/2mm,
Pale conjunctiva palpebral inferior: (-)
CVS: stable
HR: 140 bpm, regular without murmur
Pulse: 140 bpm, regular, p/v sufficient,
Warm acral, CRT <3
Respiratory system: unstable
Flow 8 litre per minute,
50 bpm regular without ronchi
Metabolic system: unstable
Blood glucose (20/7): 65mg/dL
Infectious : unstable
Fever (-) Temp: 37C
Leucocyte (20/7) : 23 310 PCT: 0.43
Hematologic : unstable
Hb/Ht/T: 17.2/50/391 000
IT Ratio: 0.16 CRP: <0.7
Musculoskeletel: stable
1.
2.
3.
4.
32
CNS: stable
Sensorium: CM Temp: 36.8C
Head: Frontal within normal limit
Eyes: Light reflex (+/+), isochoric pupil, diameter 2mm/2mm,
Pale conjunctiva palpebral inferior: (-)
CVS: stable
HR: 142 bpm, regular without murmur
Pulse: 142 bpm, regular, p/v sufficient,
Warm acral, CRT <3
Respiratory system: unstable
45 bpm regular without ronchi
Metabolic system: unstable
Blood glucose (20/7): 65mg/dL
Infectious : unstable
Fever (-) Temp: 36.8C
Leucocyte (20/7) : 23 310 PCT: 0.43
Hematologic : unstable
Hb/Ht/T: 17.2/50/391 000
IT Ratio: 0.16 CRP: <0.7
Musculoskeletel: stable
1. Respiratory distress ec Hyaline membrane disease
2. Low Birth Weight
3. Premature neonate
4. Suspect sepsis
33
CNS: stable
Sensorium: CM Temp: 36.8C
Head: Frontal within normal limit
Eyes: Light reflex (+/+), isochoric pupil, diameter 2mm/2mm,
Pale conjunctiva palpebral inferior: (-)
CVS: stable
HR: 145 bpm, regular without murmur
Pulse: 145 bpm, regular, p/v sufficient,
Warm acral, CRT <3
Respiratory system: unstable
45 bpm regular without ronchi
Metabolic system: unstable
Blood glucose (20/7): 65mg/dL
Infectious : unstable
Fever (-) Temp: 36.8C
Leucocyte (20/7) : 23 310 PCT: 0.43
Hematologic : unstable
Hb/Ht/T: 17.2/50/391 000
IT Ratio: 0.16 CRP: <0.7
Musculoskeletel: stable
1. Respiratory distress ec Hyaline membrane disease
2. Low Birth Weight
3. Premature neonate
4. Suspect sepsis
34
CNS: stable
Sensorium: CM Temp: 36.8C
Head: Frontal within normal limit
Eyes: Light reflex (+/+), isochoric pupil, diameter 2mm/2mm,
Pale conjunctiva palpebral inferior: (-)
CVS: stable
HR: 143 bpm, regular without murmur
Pulse: 143 bpm, regular, p/v sufficient,
Warm acral, CRT <3
Respiratory system: unstable
45 bpm regular without ronchi
Metabolic system: unstable
Blood glucose (20/7): 65mg/dL
Infectious : unstable
Fever (-) Temp: 36.8C
Leucocyte (20/7) : 23 310 PCT: 0.43
Hematologic : unstable
Hb/Ht/T: 17.2/50/391 000
IT Ratio: 0.16 CRP: <0.7
Musculoskeletel: stable
Lab result: Hb/Ht/L/Tr : 17.8/52/14.120/449.000
Bilirubin total: 14.2 Bilirubin direk: 0.6
SGOT/SGPT: 43/6
35
36
CNS: stable
Sensorium: CM Temp: 36.8C
Head: Frontal within normal limit
Eyes: Light reflex (+/+), isochoric pupil, diameter 2mm/2mm,
Pale conjunctiva palpebral inferior: (-)
CVS: stable
HR: 143 bpm, regular without murmur
Pulse: 143 bpm, regular, p/v sufficient,
Warm acral, CRT <3
Respiratory system: unstable
45 bpm regular without ronchi
Metabolic system: unstable
Blood glucose (27/7): 35mg/dL
Infectious : unstable
Fever (-) Temp: 36.8C
Leucocyte (27/7) : 14120
Hematologic : unstable
Hb/Ht/T: 17.8/52/449 000
Total bilirubin/ direct bilirubin/ SGOT/SGPT : 14.2/0.6/43
Musculoskeletel: stable
1. Respiratory distress ec Hyaline membrane disease
2. Low Birth Weight
3. Premature neonate
4. Suspect sepsis
- infant incubator with target temperature of 36.5 37.5 C
- Total fluid requirement: 150cc/kgBW/day
Parenteral: 40cc/kgBW/day = 66.5cc/day
IVFD D10% NaCl 0.255% (43cc) + D10% (70cc) +Ca Gluconas 10cc = 2cc/hour
Aminosteril 2gr/kgBW/day: 1.37cc/hour
Ivelip 2gr/kgBW/day : 20cc/day = 0.41cc/hour
Enteral: 110cc/kgBW/day: 11cc/2hour/OGT
- Inj ceftridine 65mg/12hour/iv
- Inj gentamicin 6.5mg/36hour/iv
- Nystatin drop 4x0.5cc
- Zamel drop 1x0.3cc
37
CNS: stable
Sensorium: CM Temp: 36.8C
Head: Frontal within normal limit
Eyes: Light reflex (+/+), isochoric pupil, diameter 2mm/2mm,
Pale conjunctiva palpebral inferior: (-)
CVS: stable
HR: 140 bpm, regular without murmur
Pulse: 140 bpm, regular, p/v sufficient,
Warm acral, CRT <3
Respiratory system: unstable
42 bpm regular without ronchi
Metabolic system: unstable
Blood glucose (27/7): 35mg/dL
Infectious : unstable
Fever (-) Temp: 36.8C
Leucocyte (27/7) : 14120
Hematologic : unstable
Hb/Ht/T: 17.8/52/449 000
Total bilirubin/ direct bilirubin/ SGOT/SGPT : 14.2/0.6/43/6
Musculoskeletel: stable
1. Respiratory distress ec Hyaline membrane disease
2. Low Birth Weight
3. Premature neonate
4. Suspect sepsis
- infant incubator with target temperature of 36.5 37.5 C
- Total fluid requirement: 150cc/kgBW/day
Parenteral: 20cc/kgBW/day = 66.5cc/day
IVFD D10% NaCl 0.255% (43cc) + D10% (70cc) +Ca Gluconas 10cc = 1cc/hour
Enteral: 130cc/kgBW/day: 14cc/2hour/OGT
- Inj ceftridine 65mg/12hour/iv
- Inj gentamicin 6.5mg/36hour/iv
- Nystatin drop 4x0.5cc
- Zamel drop 1x0.3cc
38
CNS: stable
Sensorium: CM Temp: 36.8C
Head: Frontal within normal limit
Eyes: Light reflex (+/+), isochoric pupil, diameter 2mm/2mm,
Pale conjunctiva palpebral inferior: (-)
CVS: stable
HR: 146 bpm, regular without murmur
Pulse: 146 bpm, regular, p/v sufficient,
Warm acral, CRT <3
Respiratory system: unstable
44 bpm regular without ronchi
Metabolic system: unstable
Blood glucose (27/7): 35mg/dL
Infectious : unstable
Fever (-) Temp: 36.8C
Leucocyte (27/7) : 14120
Hematologic : unstable
Hb/Ht/T: 17.8/52/449 000
Total bilirubin/ direct bilirubin/ SGOT/SGPT : 14.2/0.6/43/6
Musculoskeletel: stable
39
CNS: stable
Sensorium: CM Temp: 36.8C
Head: Frontal within normal limit
Eyes: Light reflex (+/+), isochoric pupil, diameter 2mm/2mm,
Pale conjunctiva palpebral inferior: (-)
CVS: stable
HR: 140bpm, regular without murmur
Pulse: 140 bpm, regular, p/v sufficient,
Warm acral, CRT <3
Respiratory system: unstable
40 bpm regular without ronchi
Metabolic system: unstable
Blood glucose (27/7): 35mg/dL
Infectious : unstable
Fever (-) Temp: 36.8C
Leucocyte (27/7) : 14120
Hematologic : unstable
Hb/Ht/T: 17.8/52/449 000
Total bilirubin/ direct bilirubin/ SGOT/SGPT : 14.2/0.6/43/6
Musculoskeletel: stable
40
CNS: stable
Sensorium: CM Temp: 36.8C
Head: Frontal within normal limit
Eyes: Light reflex (+/+), isochoric pupil, diameter 2mm/2mm,
Pale conjunctiva palpebral inferior: (-)
CVS: stable
HR: 145bpm, regular without murmur
Pulse: 145 bpm, regular, p/v sufficient,
Warm acral, CRT <3
Respiratory system: unstable
46 bpm regular without ronchi
Metabolic system: unstable
Blood glucose (27/7): 35mg/dL
Infectious : unstable
Fever (-) Temp: 36.8C
Leucocyte (27/7) : 14120
Hematologic : unstable
Hb/Ht/T: 17.8/52/449 000
Total bilirubin/ direct bilirubin/ SGOT/SGPT : 14.2/0.6/43/6
Musculoskeletel: stable
41
S
O
S
O
42
S
O
43
CHAPTER IV
DISCUSSION
Theory
Case
Definition
Prematurity is a term for the broad The gestational age was 28 weeks.
category of neonates born at less than
37 weeks' gestation. Preterm birth is
the leading cause of neonatal mortality
and the most common reason for
antenatal hospitalization. For premature
infants born with a weight of less than
1000 g, the 3 primary causes of
mortality
are
respiratory
failure,
44
-Genitalia
Diagnosis
Laboratory studies
Initial laboratory studies in cases of
prematurity are performed to identify
issues that, if corrected, improve the
patient's outcome. Such tests include
the following:
Numerous
found
neutrophil
types
45
Theory
Definition
Case
Baby AD is a preterm baby with
early
comprising
respiratory
cyanosis,
distress
grunting,
and
it
is
mainly,
but
not
continuous
positive
airway
by
tachypnea
(>60
46
toes.
Through
physical
examination
ventilation
suprasternal.
to
compensate
for
compliant
lungs.
Grunting
features
hypotension,
hyperkalemia.
may
include
acidosis
and
The
typical
chest
reticular
granular
out
of
the
lung
fields.
findings.
Acute
47
ROP,
and
neurologic
impairment.
Diagnosis
Clinical criteria:
- Cyanosis
- Apnea
respiratory distress:
- Nasal flaring
a) Cinical manifestation
- Rapid breathing
- Shallow breathing
- Shortness of breath and grunting
sounds while breathing
- Increased oxygen requirement
- Paradoxical chest wall movement
with breathing
- Breath sounds that include rales
- Poor lung aeration
- Accessory muscle usage
- Chest x-ray showing atelectasis, air
bronchograms, and granular
infiltrates
Therapy
Therapy which is given for RDS is:
-Respiratory
management
through
CPAP
- Antibiotic therapy such as ampicilin
48
and gentamicin.
SUMMARY
Baby AD, a boy, 1 hour old, with 1.33 kg of BW and 38 cm of BH, came to
RSUP Haji Adam Malik Medan on 20thJuly at 6:30 AM with premature birth as
a chief complaint. No history of milk feeding after birth. History of turning
blue found after birth and according to parents, blue has been found in lips,
fingers and toes. Theres no fever and history of fever also not found. Patient
found to have difficulty in breathing when admitted to Perinatology Division.
Patient was diagnosed with premature birth, Respiratory Distress ec dd/ Hyalin
Membrane Syndrome, neonatal pneumonia, low birth weight and suspect of
sepsis. Patient was treated with Infant Radiant Warmer Theraphy with target
skin temperature 36,5-37,5, total fluid requirement: 150 cc/kgBW/day = 210cc/
day, parenteral 150cc/kgBW/day = 210cc/day, IVFD D5% NaCl 0,225%
(500cc) + D40% (50cc) + KCl 10 mEq + Ca Gluconas 10cc: 4cc/hour ;GIR: 7.3
kg/kgBW/minute (D8%), Aminosteril 6% 2gr/kgBW/day = 2,8 gr/day =
47cc/day = 1,9cc/hour/iv, Enteral: Fasting for 24 hours, Ceftazidime injection
65mg/12 hour/iv, Gentamicin injection 6.5mg/36 hour/iv.
49
REFERENCE
of
Dimes
Web
site.
Premature
birth.
Available
at:
2006.
AccessedMay
7,
http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=35693.
2007,
at:
50