Anda di halaman 1dari 75

CASE REPORT

Respiratory Distress of
The Newborn
Pembimbing : dr. Nafis, Sp. A.

RSUD POLEWALI MANDAR


TAHUN 2018
IDENTITAS

Nama : By. Ny. N

Jenis Kelamin : Perempuan

Tanggal Lahir : 21 Juni 2018

Jam Lahir : 19.45 WITA

Persalinan : SC
RIWAYAT PENYAKITSEKARANG
Selama
kehamilan
Ibu N, 20 tahun, G1P0A0, gravid 40 minggu menurut HPHT
dirujuk ke Ponek RSU Polewali pada tanggal 21 Juni 2018, pukul
17.15 dengan keluhan mulas sejak 4 jam ya. Pasien mengaku
keluar air dari kemaluan yang tidak bisa ditahan sejak 1 hari
SMRS. Keluhan lain demam sejak 1 hari SMRS. Setelah dilakukan
VT didapatkan pembukaan 4. Hasil DJJ 168x/menit. Pasien
akhirnya direncanakan untuk SC atas indikasi gawat janin
(dengan inpartu kala 1 fase aktif, PEB, KPD).
RIWAYAT PENYAKIT SEKARANG
Selama
kehamilan
Selama kehamilan, Ny. N menjalankan ANC sebanyak 7x di Bidan,
Ny N mendapat imunisasi TT 2x. Ny. N mengakui adanya
hipertensi selama kehamilan. Ny. N menyangkal adanya
keputihan berbau dan gatal, demam, diabetes melitus, dan
konsumsi NAPZA selama kehamilan
Intervensi : ANC
Hasil : -
RIWAYAT PENYAKIT SEKARANG
MRS (21
JUNI)
Saat diperiksa, Tanda-tanda vital NY L didapatkan TD
160/100 mmHg, HR 88x/menit, RR 24x/menit T 38,7°C.
DJJ 168x/menit.

Intervensi : SC
Hasil : By. Ny. N lahir secara SC
RIWAYAT PENYAKIT SEKARANG
Resusitasi
neonatus
By. Ny. N lahir secara SC pada tanggal 21 Juni 2018 pk 19.45. Ketuban
ibu berwarna mekoneal, tidak berbau. Saat lahir bayi langsung
menangis, tonus otot baik, bayi segera di resusitasi dan didapatkan:
Menit 1: Bayi dihangatkan, diposisikan, dikeringkan, disuction dan
diberikan rangsang taktil kemudian HR didapatkan HR 155x/menit
dengan akrosianosis, menangis lemah, tonus otot baik, terdapat
retraksi dan grunting, APGAR 7.
Menit 5: didapatkan HR 160x/menit tanpa sianosis, menangis lemah,
dan tonus otot baik, terdapat retraksi dan grunting, APGAR 9.
Intervensi : resusitasi neonatus
Hasil : By. Ny. N diobservasi pernapasan dan saturasi selama 4 jam
RIWAYAT PENYAKIT DAHULU
 Riwayat Diabetes Melitus: disangkal

 Riwayat Hipertensi: disangkal

 Riwayat Asma: disangkal

 Riwayat trauma: disangkal

 Riwayat operasi: disangkal

 Riwayat Alergi
 Makanan:disangkal
 Obat:disangkal
 Lain-lain: disangkal
RIWAYAT KEHAMILAN

 Keadaan ibu selama kehamilan : mual dan muntah pada


trimester 1

 ANC : Dilakukan sebanyak 7x di Bidan

 Imunisasi : TT 2x

 Obat yang dikonsumsi selama kehamilan : tidak ada

 Alkohol, NAPZA, merokok : disangkal


RIWAYAT KELAHIRAN
Anak Lahir SC/PS Ditolon BBL PBL Penyulit
ke Tahun P g oleh (gram) (cm) selama
kehamilan
1 Hamil Hipertensi
ini
RIWAYAT KELUARGA

 Riwayat asma (-)

 Riwayat DM (-)

 Riwayat hipertensi (+)


SILSILAH KELUARGA

Tn. I, Ny. N,
28 th 20 th

By.Ny.N
FAKTOR RESIKO SEPSIS
Faktor Resiko Sepsis Mayor Faktor Resiko Sepsis Minor
Ketuban pecah dini (≥ 18 jam) (+) Ketuban pecah dini (> 12 jam) (-)
Demam intrapartum (> 38 0C) (+) Demam intrapartum (> (-)
37,50C)
DJJ > 160 kali/menit (+) APGAR rendah (<5 / <7) (+)
Korioamnionitis: BBLSR (< 1500 gram) (-)
Demam maternal (> 380C) (+) Usia kehamilan < 37 minggu (-)
Takikardi maternal (> 100 kali/mnt) (-)
Takikardi fetal (> 160 kali/menit) (+) Gemelli (-)
Uterin tenderness (-) Keputihan (-)
Ketuban berbau (-)
Infeksi saluran kemih (-)
ANAMNESIS & PEMERIKSAAN FISIK

 HPHT : 12 September 2017


 TUJ : 40 minggu
 TBJ : 3,565 gram menurut TFU
 Tanda-tanda vital
 Tekanan darah : 160 / 100 mmHg
 Heart rate : 88 x / menit
 Respiratory rate : 24 x / menit
 Suhu : 38.7 0C

 DJJ : 168x / menit


PEMERIKSAAN LABORATORIUM Ny.N

 Darah Rutin
 Leukosit : 18.700 /uL
 Hemoglobin : 11,3 g/dL
 Trombosit : 221.000 /uL

 HBsAg :-

 Golongan darah : A (RH +)


APGAR SCORE
SCORE MINUTE
SIGN
0 1 2 1 5
Appeara Sianosis Akrosianos Completely
1 2
nce sentral is pink
Pulse Absent <100 x/min >100 x/min 2 2
Good (with
No
Grimace Grimace cry) or cough 1 2
response
or sneeze
Some Active
Activity Limp 2 2
Flexion movement
Respirat Slow
0 Good crying 1 1
ory irreguler
TOTAL SCORE 7 9
ANTROPOMETRI

 Berat Badan Lahir : 3100 gram

 Panjang Badan Lahir : 48 cm

 Lingkar Kepala : 34 cm

 Lingkar Dada : 33 cm

 Lingkar Perut : 28 cm
PEMERIKSAAN FISIK
(SAAT OBSERVASI)
Keadaan Umum : Aktif

Kesadaran : Alert

Tanda-tanda vital :

Laju Jantung : 152 x/menit (100 – 160 x/menit)

Laju Nafas : 60 x/ menit (40 – 60x/menit)

Suhu : 36.5 0C (36.5 – 37.5oC)

Refleks : Moro (+), Rooting (+), Sucking (+), Plantar grasp (+),
Palmar grasp (+)
PEMERIKSAAN FISIK
Kepala : normocephali, deformitas (-), UUB 2 x 1 cm, teraba
lembut dan datar, molase coronal/ sagital/ lamboidea (0/2/0),
caput succedaneum (-)

Wajah : simetris

Mata : konjungtiva anemis -/-, sklera ikterik -/-

Hidung : deviasi septum –, sekret -/-, nasal flaring -/-

Telinga : meatus akustikus eksternus +/+, sekret -/-

Mulut : palatum intak, mukosa oral basah, grunting +

Leher : trakea teraba di tengah, pembesaran KGB (-), massa


PEMERIKSAAN FISIK
Paru-paru
 I : gerakan napas simetris, retraksi subkostal, interkostal
 P : gerakan napas teraba simetris
 A : air entry +/+, bronkial +/+, wheezing -/-, rhonki /-
Jantung
 I : IC tidak terlihat
 P : IC tidak teraba
 A : S1 dan S2 reguler, murmur (-), gallop (-)
Abdomen
 I : globular, umbilical cord (+)
 A : bising usus (+)
 P : supel, organomegali (-)
PEMERIKSAAN FISIK

Genitalia : labia mayor menutupi labia minor dan clitoris

Bokong : anus (+)

Punggung : alignment vertebrae baik, sacral dimple (-)

Ekstremitas : akral hangat, CRT <2s

Kulit : rash (-), jaundice (-), sentral sianosis (-)


DOWNE SCORE
RESUME ASSESSMENT
Bayi perempuan lahir dari ibu G1P0A0, usia 20 tahun, usia By. Ny. L, neonatus cukup bulan,
gestasi 40 minggu menurut HPHT dengan SC. Riwayat ANC
7x, hipertensi (+). Terdapat faktor risiko sepsis. Saat lahir sesuai masa kehamilan, APGAR
bayi menangis dengan tonus otot baik. APGAR menit 1: 7, menit I = 7, menit V = 9, BBL
menit 5: 9. Bayi menangis lemah dan terdapat grunting
dan retraksi. Kemudian bayi diobservasi. 3100 gram, PBL 48 cm, lingkar
Pada pemeriksaan fisik didapatkan kepala 34 cm, jenis kelamin
Keadaan umum : tampak aktif
Kesadaran : alert perempuan, dengan diagnosis
TTV respiratory distress
HR : 152 x / menit
RR : 60 x / menit
S : 36.5oC
BBL : 3100 gram

PBL : 48 cm
Refleks : Moro +, sucking +, rooting +, Palmar grasp +,
Plantar Grasp +
Downe score 5 (respiratory distress)
TATA LAKSANA
 Rawat NICU level II • Injeksi Vit K 1 mg IM
 Pasang CPAP(FiO2 40%, • Oxytetracycline salep
PEEP 6 mmHg) mata ODS
• Injeksi vaksin hep B 0,5
 Cek darah rutin
cc IM
 Kebutuhan cairan hari
pertama 60 cc/kgBB (186
cc) per 24 jam  ASI
8x20cc per OGT

Respiratory Distress in Newborn
THE FIRST BREATH
THE FIRST BREATH
Neonatal Respiratory Distress 
Signs and symptoms
 Tachypnea (RR > 60/min)
 Nasal flaring
 Retraction
 Grunting
 +/- Cyanosis
 +/- Desaturation
 Decreased air entry
Downe score 

Neonatal Respiratory Distress Etiologies

Pulmonary Systemic
Metabolic (e.g.,
Anatomic
Transient tachypnea of hypoglycemia, hypothermia
the newborn (TTN) or hyperthermia)
Upper airway
metabolic acidosis obstruction
Respiratory distress
syndrome (RDS) Airway
anemia, polycythemia malformation
Pneumonia Rib cage anomalies
Cardiac
• Congenital heart disease;
Meconium aspiration Diaphragmatic
cyanotic or acyanotic
syndrome (MAS) disorders
• Congestive heart failure
• Persistent pulmonary (e.g., congenital
Air leak syndromes hypertension of the newborn diaphragmatic
(PPHN) hernia,
Pulmonary
hemorrhage diaphragmatic
Neurological (e.g., prenatal paralysis)
asphyxia, meningitis)
Pulmonary
 1- Transient tachypnea of newborn

 2- Hyaline membrane disease

 3- Meconium aspiration syndrome (MAS)

 4- Pneumonia

 5- Air Leak Syndromes


Transient Tachypnea of Newborn

 TTN (known as wet lung) is a relatively mild,


self limiting disorder of near-term or term
 Delay in clearance of fetal lung fluid results in
transient pulmonary edema. The increased
fluid volume causes a reduction in lung
compliance and increased airway resistance.
Transient Tachypnea of Newborn

Risk factors:
 Maternal asthma

 C- section

 Macrosomia, maternal diabetes

 Prolonged labor, Excessive maternal sedation

 Fluid overload to the mother,Delayed clamping of the


umbilical cord .
Transient Tachypnea of Newborn
 Usually near-term or term
 Tachypnea immediately after birth or within 6 hrs
after delivery, mild to moderate respiratory distress.
 These manifestations usually persist for 12-24 hrs,
but can last up to 72 hrs
 Auscultation usually reveals good air entry with or
without crackles or wheeze
 Spontaneous improvement of the neonate is an
important marker of TTN.
Transient Tachypnea of Newborn
Chest x-ray :
 Fluid in the intralobar fissure

 Prominent pulmonary vascular markings

 Hyperinflation of the lungs, with depression of


diaphragm
 Rarely, small pleural effusion

 ► Chest x-ray usually shows evidence of clearing by 12-


18 hrs with complete resolution by 48-72 hrs
chest X-ray: Transient Tachypnea of Newborn

Fluid in the
fissure
General Management of Respiratory Distress

 Supplemental oxygen or MV, if needed.

 Continuously monitor with pulse oximeter.

 Obtain a chest radiograph.

 Correct metabolic abnormalities


(acidosis,hypoglycemia).
 Obtain a blood culture & begin an antibiotic
coverage (ampicillin + gentamicin)
General Management

 Provide an adequate nutrion. Infants with


sustained RR >60 breaths/min should not be fed
orally & should be maintained on gavage feedings
for RR 60-80 breaths/min, and NPO with IV fluids
or TPN for more severe tachypnea
Pulmonary
 1- Transient tachypnea of newborn

 2- Hyaline membrane disease

 3- Meconium aspiration syndrome (MAS)

 4- Pneumonia

 5- Air Leak Syndromes


Respiratory Distress Syndrome
 Also called as hyaline membrane disease
 Most common cause of respiratory distress in
premature infants, correlating with structural &
functional lung immaturity.
 primarily affects preterm infants; its incidence is
inversely related to gestational age and
birthweight.
 15-30% of those between 32-36 weeks‘ gestation,
in about 5% beyond 37 weeks' gestation
Physiologic abnormalities
 Surfactant deficiency- increase in alveolar
surface tension + collapse of of small air
spaces at end expiration.
 Lung compliance decreased to 10-20% of normal
 Atelectasis…areas not ventilated
 Decrease alveolar ventilation
 Reduce lung volume
 Areas not perfused
Surfactant Function
Normal Expiration Abnormal Respiration
With Surfactant Without Surfactant
Risk factors
 Prematurity

 Maternal diabetes

 Multiple births

 Elective cesarean section without labor

 Perinatal asphyxia

 Cold stress

 Genetic disorders
Decreased risk

 Chronic intrauterine stress


 Prolonged rupture of membranes
 Antenatal steroid prophylaxis
Clinical Manifestations
 Appear within minutes of birth may not be recognized for several
hours in larger preterm

 Tachypnea (>60 breaths/min), nasal flaring, subcostal and intercostal


retractions, cyanosis & expiratory grunting

 Breath sounds may be normal or diminished and fine rales may be


heard

 Progressive worsening of cyanosis & dyspnea. BP may fall; fatigue,


cyanosis and pallor increase & grunting decreases.

 Apnea and irregular respirations are ominous signs

 In most cases, symptoms and signs reach a peak within 3 days, after
which improvement occurs gradually.
Chest x-ray:
Findings can be graded according to the severity:

 Grade 1 (mild cases): the lungs show fine


homogenous ground glass shadowing
(reticulogranular / ground glass appearance)
 Grade 2: widespread air bronchogram become
visible (air bronchogram)
 Grade 3: confluent alveolar shadowing
(mediastinum melebar)
 Grade 4: complete white lung fields with obscuring
of the cardiac shadow
Grade 1
Grade 2
Grade 3
Grade 4
Management
Prevention:
 Lung maturity testing: lecithin/sphingomyelin (L/S) ratio >=2

 Tocolytics to inhibit premature labor.

 Antenatal corticosteroid therapy:

► They induce surfactant production and accelerate fetal lung


maturation.
► Are indicated in pregnant women 24-34 weeks' gestation at
high risk of preterm delivery within the next 7 days.
► Optimal benefit begins 24 hrs after initiation of therapy and
lasts seven days.
Prevention
 Antenatal corticosteroid therapy consists of either :
□ Betamethasone 12 mg/dose IM for 2 doses, 24 hrs apart, or
□ Dexamethasone 6 mg/dose IM for 4 doses, 12 hrs apart

 Early surfactant therapy: prophylactic use of


surfactant in preterm newborn <27 weeks'
gestation.
 Early CPAP administration in the delivery room.
Treatment
 Administer warm humidified oxygen  target PaO2
50-70 mmHg (SpO2 91-95%)
 Initiate CPAP nasal prongs as early as possible in
infants with mild RDS if SpO2 < 90% at inspired oxygen
concentration 40-70%  reduces ventilatory needs.
Treatment

 Start assisted MV if respiratory acidosis (pH <7,20, PaCO2 >60


mmHg, PaO2 <50 mmHg or SaO2 <90%) with an FiO2 >0.5, or
severe frequent apnea.

 Administer surfactant therapy: early rescue therapy within 2


hrs after birth is better than late rescue treatment when the
full picture of RDS is evident.
Types of Surfactant
Natural Surfactants: contain appoproteins SP-B & SP-C
 Curosurf (extract of pig lung mince)

 Survanta (extract of cow lung mince)

 Infasurf (extract of calf lung)

Synthetic Surfactants:do not contain proteins


 Exocerf

 ALEC

 Lucinactant (Surfaxin)
Surfactant Therapy for RDS

 Improvement in compliance, functional


residual capacity, and oxygenation
 Reduces incidence of air leaks
 Decreases mortality

60
Mode of administration of Surfactant

 Dosing may be
divided into 2
alliquots and
adminitered via
a 5-Fr catheter
passed in the
ET
Pulmonary
 1- Transient tachypnea of newborn

 2- Hyaline membrane disease

 3- Meconium aspiration syndrome (MAS)

 4- Pneumonia

 5- Air Leak Syndromes


Meconium Aspiration Syndrome

Risk Factors:
 Post-term pregnancy

 Pre-eclampsia, eclampsia, maternal hypertension,

 Maternal diabetes mellitus

 IUGR

 Evidences of fetal distress (e.g.,abnormal biophysical


profile)
Clinical Manifestations
 Meconium staining amniotic fluid (meconium stained
nails, skin & umbilical cord )
 Some infants may have mild initial respiratory
distress, which becomes more severe hours after
delivery.
 Pneumothorax and/or pneumomediastinum

 PPHN in severe cases

 Hypoxia to other organs (e.g., seizures, oliguria)


Chest x-ray: Areas of hyperexpansion mixed with patchy
densities and atelectasis
Management
In the DR or OR:
 Visualization of the vocal cords & tracheal suctioning before
ambu-bagging should be done only if the baby is not vigorous

In the NICU:
 Empty stomach contents to avoid further aspiration.

 Suction frequently & perform chest physiotherapy.


Management
 Consider CPAP, if FiO2 requirements >0.4; however CPAP may
aggravate air trapping and must be used cautiously.
 Mechanical ventilation: in severe cases (paCO2 >60 mmHg
orpersistent hypoxemia (paO2 <50 mmHg).
 Correct systemic hypotension (hypovolemia, myocardial
dysfunction).
 Manage PPHN, if present

 Manage seizures or renal problems, if present.

 Surfactant therapy in infants whose clinical status continue


todeteriorate.
Pulmonary
 1- Transient tachypnea of newborn

 2- Hyaline membrane disease

 3- Meconium aspiration syndrome (MAS)

 4- Pneumonia

 5- Air Leak Syndromes


Pneumonia
Common organisms:
 GBS

 gram–ve organisms (e.g. E.Coli,


Klebsiella,Pseudomonas)
 , Staph. aureus, Staph. epidermidis

 Candida.

 acquired viral infections (e.g., HSV, CMV).


Clinical Manifestations
 Early manifestations may be nonspecific (e.g., poor
feeding, lethargy, irritability, cyanosis, temperature
instability
 Respiratory distress signs may be superimposed upon RDS

 Signs of pneumonia (dullness to percussion, change in


breathsounds, rales or rhonchi) are difficult to appreciate.
Chest x-rays: infiltrates or effusion
Management

 Initiate ampicillin and gentamicin IV;


modify according to culture results
and continue therapy for 14 days.
 If there is a fungal infection, an
antifungal agent is used.
Thank You …

Thank You …