WID Measles (Autosaved)

Case Report Kepada Yth.

Perinatology Unit

RESPIRATORY DISTRESS EC TRANSIENT TACHYPNEA OF

NEWBORN

Presenter : Muhammad Faiz Bin Hashim (100100402)

Day/Date : Friday/ June 6th 2014

Supervisor in charge : dr. Bugis Mardina Lubis, Sp.A(K)

Supervisor : dr. Bugis Mardina Lubis, Sp.A(K)

Introduction

Respiratory distress in newborn infants is common immediately after birth

and is transient in most cases. It is characterized by tachypnea, flaring of nostril

during respiration, intercostal retraction, cyanosis and apnoe.¹ There are three

common disorder that cause respiratory distress after birth: transient tachypnea

of the newborn (TTN), respiratory distress syndrome (RDS) and persistent

pulmonary hypertension (PPHN).²

Transient tachypnea of the newborn (TTN) is the most common

respiratory disorder among the newborn population. It is a clinical condition

associated with respiratory distress due to delayed evacuation of the lung fluids,

which naturally occurs before, during and immediately after the delivery process.

It was first described in 1966 as a major cause of respiratory distress in term and

near-term infants.2 In 1981, Haliday and McClure described two different clinical

entities of TTN: classical and severe.³

The incidence of the condition varies widely among centers. In a review

of 29,669 deliveries from 1992 to 1999 from a single center in the United States,

TTN occurred in more infants after elective Cesarean than after vaginal delivery

(3.1% versus 1.1%).4 In another British review of 33,289 term deliveries (37 to

42 weeks), the incidence of TTN was 5.7 per 1000 births.5 In a German study that

analyzed data from perinatal regional registries of almost 240,000 full-term

deliveries from 2001 to 2005, the incidence of TTN was 5.9 cases per 1,000

singleton births.6 Elective section was the most significant risk factor associated

with TTN compared against vaginal deliveries in data from the national German

perinatal registry (42% versus 9%). Other risk factors associated with TTN

1

included small for gestational age (16% versus 10%), large for gestational age

(14% versus 11%), and male gender (60% versus 51%). Maternal diabetes and

asthma are also well recognized risk factors.6 At HMC Women’s Hospital, the

overall incidence of classic TTN is approximately 1.0% (10 cases per 1000

singleton live birth). The rate of Caesarian section was 21% in 2010.³

The aim of this study is to explore more about the theoretical aspects on

Transient Tachypnoe of Neonates (TTN), and to integrate the theory and

application of TTN case in daily life.

2

Respiratory Distress

Definition

Respiratory distress is the condition where the respiratory effort is

increasing from the normal. It is characterized by: ⁵

1. Tachypnea: respiratory rate > 60-80x/minute

2. Retraction: Pulling in of the ribs and center of the chest with each breath.

3. Flaring of nostril when breathing in.

4. Grunting

5. Cyanosis: Bluish skin color around the nose and mouth

6. Apnoe

Etiology

1. Airway obstruction⁵

a. Nasal or pharyngeal: choanal obstruction, nasal edema,

encephalocele.

b. Oral mucosa: macroglossia, micrognathia

c. Neck: congenital struma, higroma cystic

d. Laynx: laryngeal web, subglottic stenosis, hemangioma, paralysis

medulla spinalis, and laryngomalacia

2. Trachea: tracheomalacia, tracheoesophageal fistula, tracheal stenosis, and

bronchial stenosis.

3. Lung:

a. Meconium aspiration Syndrome

b. Respiratory Distress Syndrome (RDS)

c. Atelectasis

d. Pneumothorax, pneumomediastinum, pulmonary emphysema.

e. Transient Tachypnoe of Newborn(TTN)

f. Pneumonia, hemorrhagic pneumonia

g. Congenital abnormalities: diaphragmatic hernia, intrathoracal

tumour or cyst, pulmonary hypoplasia or agenesis, and congenital

lobar emphysema.

3

h. Effusion, chylothorax

4. Non pulmonary:

a. Congestive heart failure

b. Metabolic disease: acidosis, hypoglycaemia, hypocalcemia.

c. Persistent pulmonary hypertension

d. Neonatal depression

e. Shock

f. Polycythemia

g. Hypothermia

h. Newborn with maternal DM

i. Bleeding of central nervous system

Classification

Respiratory distress can be classified based on severity of distress. It can be

done by using Downes score which is divided by three categories listed in table

below:⁵

Evaluation

Total score Diagnosis

1 – 3 Mild respiratory distress

4 - 5 Moderate respiratory distress

≥6 Severe respiratory distress

Diagnosis

Respiratory distress can be diagnosed by clinical sign or blood gas analysis.

Calculation of oxygenation index will represent how severe the hypoxemia.

Evaluation of newborn with respiratory distress must be careful. Newborn with

predominant respiratory sign may not always suffer respiratory distress such as in

metabolic acidosis and diabetic ketoacidosis but otherwise, severe respiratory

distress on newborn can occurs without respiratory sign such as in central

4

hypoventilation effect from drug intoxication or infection. A thorough evaluation

must be done based on history taking, complete physical examination,

laboratorium and radiologic finding that lead to diagnosis. Serial evaluation on

consciousness, respiratory sign, blood gas analysis and therapy responsiveness

must be taken for further intervention.

a) History taking

History taking on family , maternal, prenatal and interpartum history must be

taken, and other important point that will listed below:-⁵

Prematurity, respiratory distress syndrome, meconium aspiration

syndrome, infection: pneumonia, pulmonary dysplasia, nasal congestion,

CNS depression and bleeding, phrenic nerve paralysis, bradycardia and

tachycardia on neonates, neonatal depression, trauma during inverse

partus.

CNS depression: hypertonia, flaccidity, atonia, trauma, myasthenia

Congenital abnormalities: single umbilical artery, cardiopulmonary

anomaly, erb paralysis, choanal atresia, obstructive nasal congestion,

increased diameter of anterior posterior lung, lung hypoplasia,

tracheoesophageal fistula.

Maternal diabetes, antepartum hemorrhage, prolonged partus, premature

rupture of membrane, oligohydramnion.

b) Physical examination

On physical examination, we will find clinical sign of respiratory distress such

as:⁵

Grunting

Cyanosis

Retraction

Sign of airway obstruction (choanal obstruction)

Amniotic fluid mixed with meconium or yellowish green discolouration of

umbilicus.

Scaphoid abdomen

c) Laboratorium findings

a) Blood Gas Analysis⁵

5

o Sign of acute respiratory failure: PaCO₂ > 50 mmHg, PaO₂ <

60 mmHg, Oxygen saturation < 90%.

o Blood samples is taken from umbilical artery or arterial puction

o Indicator of metabolic acidosis, respiratory acidosis and

hypoxic condition.

o Respiratory acidosis occurs because of alveolar atelectasis

and/or lower respiratory tract overdistention.

o Metabolic acidosis usually because of primary lactic acidosis,

result from poor tissue perfusion and anaerobic metabolism.

o Hypoxia occurs when there are left to right shunt between

pulmonary circulation, PDA and/or persistent foramen ovale.

o Pulse Oxymeter is used as non invasive method for evaluate

oxygen saturation.

b) Electrolytes

o Increased in bicarbonates ion result from metabolic

compensation of chronic hypercapnia.

o Blood glucose level to eliminates hypoglycaemia

o Hypokalemia, hypocalcemia, hypophosphatemia can cause

disturbance of muscle contraction

c) Radiologic findings

o Chest x-ray: diffuse reticulo granular bilateral, or air

brochcogram and unexpanded lung.

o Cardiac silhouette: normal or enlarge

o Cardiomegaly: prenatal asphyxsia, maternal diabetes, PDA,

other congenital heart disease.

o Thorax transillumination test: detect abnormal air deposition

such as in pneumothorax.

o Detect pneumonia, pneumothorax, bilateral hyperinflation,

pleural effusion, and endotracheal tube malposition.

Treatment

6

Treatment for neonatal respiratory distress can be both generalized and

disease-specific. Physicians should be aware of current neonatal resuscitation

protocols. Oxygenation can be enhanced with blow-by oxygen, nasal cannula, or

mechanical ventilation in severe cases. Surfactant administration may be required.

Antibiotics are often administered if bacterial infection is suspected clinically or

because of leukocytosis, neutropenia, or hypoxemia. Ampicillin and gentamicin

are often used together based on their effectiveness and synergy. Extracorporeal

membrane oxygenation, similar to an artificial external lung, is used as a last

resort in critical circumstances. Oral feedings are often withheld if the respiratory

rate exceeds 80 breaths per minute.

If pneumothorax occurs, needle decompression or chest tube drainage may

be required. Small pneumothoraces can be treated in term infants without invasive

management through nitrogen washout. Administration of 100% oxygen can

accelerate the resolution of the pneumothorax as readily absorbed oxygen replaces

nitrogen in the extrapulmonary space. This technique can reduce pneumothorax

duration from two days to eight hours.

Because evidence in the specific treatment of neonatal respiratory distress

continues to evolve, family physicians should work conjointly with neonatal

intensivists. If services required for the neonate are unavailable at the family

physician's facility, care should be transferred to a higher acuity hospital.³

Transient Tachypnoe of Newborn (TTN)

Definition

TTN is a parenchymal lung disorder characterized by pulmonary edema

that results from delayed resorption and clearance of fetal alveolar fluid in term

infants. The excess fluid in the lungs in TTN results in decreased pulmonary

compliance and increased airway resistance. The mechanism causing changes in

pulmonary function are primarily associated with the extrinsic compression of

small airways by fluid in the extra-alveolar interstitium. Tachypnea develops to

compensate for the increased work of breathing associated with reduced

compliance and increased airway resistance.²

7

Risk Factors

Delivery via elective cesarean section increases the risk for TTN.Although

the physiologic mechanism are not understood, this risk is significantly decreases

if the mother undergoes the trial of labour. Additional risk factors included male

sex and macrosomia. Although the mechanism is obscure, being born to an

asthmathic mother appears to be a risk factor to TTN. Infant borns with

gestational diabetes also appear to be at increased risk. This observation may be

related toa corresponding increased the rate of caesarean section among this

mother.⁶

Pathophysiology

Noninfectious acute respiratory disease develops in approximately 1% of

all newborn infants and results in admission to a critical care unit. TTN is the

result of a delay in clearance of fetal lung liquid. Respiratory distress typically

was thought to be a problem of relative surfactant deficiency, but it is now

characterized by an airspace-fluid burden secondary to the inability to absorb fetal

lung liquid. In vivo experiments have demonstrated that lung epithelium secretes

Cl- and fluid throughout gestation but only develops the ability to actively

reabsorb Na + during late gestation. At birth, the mature lung switches from active

Cl- (fluid) secretion to active Na + (fluid) absorption in response to circulating

catecholamines. Changes in oxygen tension augment the Na + -transporting

capacity of the epithelium and increase gene expression for the epithelial Na +

channel (ENaC).

The inability of the immature fetal lung to switch from fluid secretion to

fluid absorption results, at least in large part, from an immaturity in the expression

of ENaC, which can be upregulated by glucocorticoids. Both pharmacologic

blockade of the lung's EnaC channel and genetic knockout experiments using

mice deficient in the ENaC pore-forming subunit have demonstrated the critical

physiologic importance of lungNa + transport at birth. When Na + transport is

ineffective, newborn animals develop respiratory distress; hypoxemia; fetal lung

liquid retention; and, in the case of the ENaC knockout mice, death.

Bioelectrical studies of human infants' nasal epithelia demonstrate that

both TTN and respiratory distress syndrome (RDS) have defective amiloride-

sensitive Na + transport. These results suggest that infants with neonatal RDS

8

have, in addition to a relative deficiency of surfactant, defective Na + transport,

which plays a mechanistic role in the development of the disease. An infant born

by cesarean delivery is at risk of having excessive pulmonary fluid as a result of

having not experienced all of the stages of labor and subsequent low release of

counter-regulatory hormones at the time of delivery.⁴

Diagnosis

Diagnosis of TTN is based on history taking, clinical finding, laboratorium

test and chest X-ray.

a) History taking

Signs of respiratory distress (eg, tachypnea, nasal flaring, grunting,

retractions, cyanosis in extreme cases) become evident shortly after birth.

The disorder is indeed transient, with resolution occurring usually by age

72 hours. The other risk factor also must be asked such as history of

delivery, maternal asthma, and prolonged labour.

b) Sign and Symptom

There are several symptoms of TTN. Your baby may not have all of

them. There are rapid breathing, flaring of the nostrils when breathing in,

sharp pulling in of the chest muscles during breathing (retraction) and

bluish skin color (cyanosis) around the nose and mouth.

c) Laboratorium examination

The initial evaluation may include a complete blood count and arterial

blood gases. In TTN, an arterial blood gases may reveal a mild respiratory

acidosis due to mild hypoxemia and hypercapnia; the complete blood

count and C-reactive protein are typically normal.

d) Chest radiography

On chest radiographs, classic findings for TTN include prominent

central marking suggestive of vascular engorgement, moderate

cardiomegaly, increased lung volume, and increased anteroposterior chest

diameter. A study conducted of morethan 2800 babies reported in 2003

found a subset of infants whose clinical appearance indicated TTN but

whose chest film was clear. This suggest that TTN can occurs despite of

normal chest findings.⁶

9

Management

Management of TTN is supportive. Although infants exhibiting mild

tachypnea, can usually be observed for a few hours in a newborn nursery.

Significant tachypnea (> 60-80/min) prevents oral feeding and necessitates to

higher level of care for initiation of intravenous fliud and monitoring. In selected,

situation, an orogastric or nasogastric tube can be placed for assistance with

feeding, but only after determining that the infants is unlikely to require

ventilatory support. Because of concern of gastroesophageal reflux and aspiration,

infants with respiratory rate greater than 90 to 100 breath per minutes should not

received oral or gastric feeding. However placement of an orogastric or

nasogastric tube for stomach decompression may be helpful to maximise lung

expansion. Supplemental oxygen mey be needed, and nasal continuos positive air

pressure may be required for infant exhibiting persistent and significant work of

breathing.Althuogh some has proposed that furosemide may be useful in the

treatment of TTN, studies has not comfirmed that it has any roles.⁶

10

CASE REPORT

Name : by TT

Age : 1 day

Sex : Male

Date of Admission : May, 9th 2014

Chief Complaint : dyspnea

History : this newborn named TT was delivered by cesarean section

on indication previous SC one times. Gestational age 36-37

weeks + PK + AH + inpartu + suspect congenital heart

disease. On 9th May 2014, 14.50WIB, the newborn

delivered, not crying, body and extremites was cyanosis,

Then the newborn was placed under infant warmer and

tactile stimulus and dried up was done. Then the baby

crying, the body was reddish and extremites was bluish

color. Oxygen was given by using nasal cannule, the

extremites then become reddish. The baby were observed

for 15 minutes. Then the umbilicard cord was amputated,

and wrapped with sterile gauze and was placed in

incubator.

Pregnant History

Birth History

APGAR score : 6/8. BW: 2400g, Body length: 45cm, Head circumference: 34cm.

Downes score: 4

Immunization History

Not given yet

11

Feeding History

From birth : -

History of Growth and Development

History of previous illness : -

History of previous medications : -

Physical Examination

Generalized status

Body weight: 2400g, Body length: 45 cm

Presens status

Consciousness: Alert, Body temperature: 36,8oC.

Anemic (-); Icteric (-); Cyanosis (+); Edema (-). Dyspnea (+).

Localized status

Head :

- Large crown open flattened. Head circumference: 34 cm.

- Eye: Isochoric pupil, inferior palpebra conjunctiva pale (-/-), conjunctivitis (-),

icteric sclera (-/-), light reflex (+/+).

- Face: within normal limit

- Ear: within normal limit

- Nose: nasal canule (+), Naso gastric tube (+)

- Mouth: within normal limit

Thorax:

Symmetrical fusiformis, chest retraction (+) epigastrial, HR: 164 bpm, regular,

murmur (-). RR: 62x/i, reguler, rales (-)

Abdomen:

Soepel, normal peristaltic, liver and spleen unpalpable.

Extremities:

12

Pulse 164 bpm, regular, adequate pressure and volume, warm, CRT < 3”,

Urogenital:

Male, anus (+) within normal limit.

Laboratory Findings (May 10th 2014):

Parameters Value Normal Value

Complete Blood Count

Hemoglobin 14,00 gr% 13,4 – 19,8 gr%

Hematocrite 42,20 % 51 – 65%

Erithrocyte 4,06 x 106 /mm3 5,33 – 5,47 x 106 /mm3

Leucocyte 10,46 x 103 /mm3 6.0 – 17.5x 103 /mm3

Platelet 100.000 /mm3 217.000 – 497.000 /mm3

MCV 103,90 fl 104 – 116 fl

MCH 36,00 pg 35 – 39 pg

MCHC 34,60 gr% 32 – 34 gr%

RDW 15,80 % 14,9 – 18,7 %

Diftel 0,4/ 0,2 / 62,5 / 24,9 /

12,00

1-6/0-1/37-80/20-40/2-8

13

14

Parameters Value Normal Value

Blood Gas Analysis

pH 7,277 7,35 – 7,45

pCO₂ 32,6 mmHg 38 – 42

pO₂ 183,7 mmHg 85 – 100

Bicarbonate(HCO₃) 14,9 mmol/L 22 - 26

Total CO₂ 15,9 mmol/L 19 - 25

Base Excess (BE) - 10,9 (-2) – (+2)

O₂ saturation 99,1 % 95 - 100

Carbohydrate

Blood Glucose (ad random) 56,00 <200

Electrolytes

Calcium 6,8 mg/dL 8,4 – 10,8

sodium 140 mEq/dL 135 – 155

Pottasium 4,1 mEq/dL 3,6 – 5,5

Phosphate 6,2 mEq/dL 5,0 – 9,6

Chloride 111 mEq/dL 96 - 106

Magnesium 2,63 mEq/dL 1,2 – 1,8

Autoimmune

CRP qualitative Positive

Other test

Procalcitonin 38,44 mg/dL < 0,005

Differential Diagnosis:

- Respiratory Distress ec Transient Tachypea of Newborn (TTN)

- Respiratory distress ec Hyaline Membrane Disease (HMD)

- Low Birth weight

Working Diagnosis:

Respiratory Distress ec Transient Tachypnea of Newborn (TTN) + Low

birth Weight + suspect Sepsis

Management:

- CPAP with FiO₂ 30% PEEP 6 – saturation target 88 – 92%

- Total fluid requirement 80mL / kg / day = 192 mL/day

o Parenteral 80 mL/ kg/ day = 192 mL/ day

o IVFD D10% +Ca gluconas 10 mL = 8 mL/hour

o Enteral : Trophic feeding 10 mL/kg/hour = 24mL/day

o Dipt AH IPAH 2mL/2 hour/ orogastric tube

- Inj Ceftazidine 120mg/12 hour/IV

- Inj gentamisin 12 mg/36 hour/IV

- Inj. Vit K 1mg/IM

- Replacement of wet diapers

Diagnostic Planning:

- Septic workup

- Complete blood count

- Glucose ad random

- Electrolyte (Na, K, Cl)

- Blood gas analysis

- Chest Xray

15

FOLLOW UP

May, 10th 2014

S dyspnea(+) minimal, fever(-), suckling effort weak, movement weak

O Sens: Alert, Temp: 37,0oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-)

Dyspnoe (+).

Body weight: 2,4 kg, Body length: 45 cm.

Head Large crown opened flat.

Eye: Isochoric pupil, inferior palpebra conjunctiva pale

(+), \ icteric sclera (-/-), light reflex (+/+).

Face: within normal limit

Ear: within normal limit

Nose: CPAP FiO₂ 25% flow & L/I PEEP= 6, Sat 88-90%

Mouth: inserted with orogastric tube

Neck Within normal limit

Thorax Symmetrical fusiformis, chest retraction (+) epigastrial, HR:

154 bpm, regular, murmur (-). RR: 65x/i, reguler, rales (-)

Abdomen Soeple, normal peristaltic, liver and spleen unpalpable,

Extremitie

s

Pulse 154 bpm, regular, adequate pressure and volume,

warm, CRT < 3”,

Genital Male, within normal limit.

A - Respiratory Distress ec DD/ Transient Tachypnea of Newborn

Hyaline Membrane Disease

- Suspect sepsis

- Low Birth Weight

P - CPAP with FiO₂ 21% , PEEP: 5 = saturation 89-91%

- Total fluid requirement 80mL/kg/day = 192mL/day

o Parenteral 80 mL/ kg/ day = 192 mL/ day

o IVFD D10% +Ca gluconas 10 mL = 8 gtt/I micro

o Enteral : Trophic feeding 20 mL/kg/hour = 48mL/day

o ASI/PASI : 4mL/2 hour/ OGT

16

- Inj. Ceftazidine 120mg/12 hour/ IV (D1)

Lab Result:

Hb/ He/ L/ T : 14,6/42,2/ 10460/ 100 000

pH/pCO₂/pO₂/HCO₃/TCO₂/BE/SO₂

7,27/ 32,6/ 183,3/ 14,9/ 15,9/ -10,9/ 99,1

Na./ K/ Cl/ Ca/ Mg/ P : 140/4,1/111/6,8/2,63/ 6,2

Ca: 0,889, Glucose : 56, CRP : (+), Procalcitonin: 38,44

Workup:

a) Hypoglycemia correction : 2mL/kg/ IV = 5mL (D10% bolus)

b) Hypocalcemia correction : 2mL/kg/IV = 5mL (Ca Gluconas in 5mL

D5%) , complete in 6 hours = 1,5mL/hour

May 11th 2014

S dyspnea(+) minimal, fever(-), suckling effort weak, movement weak

O Sens: Alert, Temp: 36,8oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-).

Dyspnoe (+) Body weight: 2,4 kg, Body length: 42 cm.

Head Large crown open flatten. Head circumference:


(-/-),icteric sclera (-/-), light reflex (+/+).



Nose: FiO₂ 25% flow & L/I PEEP= 6, Sat 88-90%

Mouth: orogastic tube inserted




Abdomen Rapid turgor, normal peristaltic, liver and spleen

unpalpable,

Extremitie

s


warm, CRT < 3”,



17


- Suspect sepsis

- Low Birth Weight

P Management:

- CPAP with FiO₂ 30%, PEEP 5, Saturation O₂ < 95%


o IVFD D10% + Ca gluconas 10cc = 18gtt/I micro

o Enteral; trophic feeding 30mL/kg/days = 72mL/days

o Diet ASI/PASI 6mL/2 jam/ OGT

- Inj. Ceftazidine 120mg/12 hour/IV (H2)

- Inj Gentamisin 12mg/36 hour/ IV (H2)

May 12th 2014

S Dyspnea(+), fever(-), suckling effort weak, movement weak

O Sens: Alert, Temp: 37,0oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-).

Dyspnoe (+)

Head Large crown open flatten. Eye: Isochoric pupil, inferior

palpebra conjunctiva pale (-/-), icteric sclera (-/-), light

reflex (+/+).



Mouth: inserted with OGT,




Abdomen Rapid turgor, normal peristaltic, liver and spleen unpalpable

Extremitie

s


warm, CRT < 3”.




- Suspect sepsis

- Low Birth Weight

18

P Management:

- CPAP with FiO₂ 21% PEEP 5 ,O₂ saturation 91%

- Total fluid requirement = 110mL/kg/day

o Parenteral 70mL/kg/day = 168mL/day

o IVFD D10% + Ca Gluconas 10mL = 7mL/hour

o Enteral trophic feeding: 40mL/day = 96mL/day

o Diet PASI/ASI : 8mL/2 hour/OGT

- Inj. Ceftazidine 120mg/12hour/IV

- Inj. Gentamisin 12mg/36hour/IV

May 13thͪͪͪͪͪͪͪͪͪ 2014

S Dyspnea(+), fever(-), suckling effort weak, movement weak, jaundice(+)

O Sens: Alert, Temp: 36,8oC. Anemic (-). Icteric (+). Edema (-). Cyanosis (-).

Head Large crown opened flat.Eye: Isochoric pupil, inferior

palpebra conjunctiva pale (-/-),icteric sclera (-/-), light reflex

(+/+).



Nose: within normal limit, nasal cannule low flow

0,5L/min, O₂ saturation 90-93%.

Mouth: OGT(+)


Thorax Symmetrical fusiformis, chest retraction (+) epigastic and

suprasternal, HR: 148 bpm, regular, murmur (-). RR: 60x/i,

regular.

Abdomen normal peristaltic, liver and spleen unpalpable,

Extremitie

s


warm, CRT < 3”,


A - Respiratory distress ec Transient tachypnea of Newborn + icteric

neonatorum + susp sepsis + Low birth weight

P Management:

19

- Radian infant warmer target skin temperature 36,5 – 37,5°C.

- O₂ nasal cannule low flow 0,5L/min

- Toral fluid requirement 130mL/kg/day = 312mL/day


o IVFD D5%, NaCl 0,225%(430mL) + D10%(70mL) + KCl 10mEq +

Ca Gluconas 10mL = 18gtt/I micro

o Enteral 50mL/kg/day = 120mL/day

o Diet PASI/ASI 10mL/2hour/OGT

- Inj Ceftazidine 120mg/12hour/IV (D4)

- Inj. Gentamisin 12mg/36hour/IV (D4)

- Nystatin Drop 3 x 0,5cc

Laboratorium finding

Billirubin total : 10,74 Bilirubin direct: 0,36 Glucose: 85,5

Na/K/Cl/Ca/Mg/P : 141/4/109/8,4/3,01/5,8

pH/pCO₂/pO₂/HCO₃/TCO₂/BE/SO₂/Ca : 7,316/33,6/129,1/16,7/17,8/-

8,5/98,3/1,1

May 14th 2014

S Dyspnea(+) minimal, icterus(+), suckling effort weak


Dyspnoe (-) Body weight: 2,2 kg,

Head Large crown open flattend.

Eye: Isochoric pupil diameter 3mm, inferior palpebra

conjunctiva pale (-/-), light reflex (+/+).


Ear/Nose: within normal limit,

Mouth: within normal limit


Thorax Symmetrical fusiformis, chest retraction (+) epigastrial,

vesicular, HR: 148 bpm, regular, murmur (-). RR: 58x/i,

reguler, rales (-).


Extremitie Pulse 148 bpm, regular, adequate pressure and volume,

20

s warm, CRT < 3”.


A - Respiratory distress ec Transient tachypnea of newborn +

hiperbilirubinemia indirect+ susp sepsis + low birth weight.

P Management:

- Infant radiant warmer target skin temperature 36,5- 37,5°C.

- CPAP FiO₂ 21%, PEEP 5, flow 5L/i

- 24 hour light therapy



o IVFD D5% NaCl 0,225%(430mL), D40%(70mL), KCl 10mEq + Ca

Gluconas 10mL = 7gtt/i micro



- Inj. Ceftazidine 120mg/12hour/IV (D5)


- Nystatin drop 3 x 0,5mL

May 15th 2014

S Dyspnea(+) minimal, icterus (+), suckling effort weak, active movement


Head Large crown open flat.

Eye: Isochoric pupil, inferior palpebra conjunctiva pale (-/-),

light reflex (+/+).



Nose: CPAP FiO₂ 21%,PEEP 5, O₂ saturation 90-92%



148 bpm, regular, murmur (-). RR: 58x/i, reguler,


Extremitie

s


warm, CRT < 3”.

21




P Management:


- CPAP FiO₂ 21%, PEEP 5, flow 8L/i









- Nystatin drop 3 x 0,5mL

May 16th 2014

S Dyspnea(+) minimal, icterus (+), suckling effort weak, active movement


Head Large crown open flatten.

Eye: Isochoric pupil, inferior palpebra conjunctiva pale (-/-),

light reflex (+/+).



Nose: Nasal cannule inserted



146 bpm, regular, murmur (-). RR: 56x/i, regular, vesicular.


unpalpable.

Extremitie

s


warm, CRT < 3”.


22



P Management:


- O₂ nasal cannule low flow 0,5L/i









Nystatin drop 3 x 0,5mL

Further plan

- Blood culture, CBC, BGA, Electrolytes,Bilirubin, glucose, CRP, PC

May 17th 2014

S Dyspnea(+) minimal,icterus(+), suckling effort weak

O Sens: Alert, Temp: 36,9oC. Anemic (-).Edema (-). Cyanosis (-).Body weight:

2,11kg..

Head Large crown open flatten.


(-/-),light reflex (+/+).

Face: icteric(+)


Nose: O₂ nasal cannule inserted

Mouth: orogastric tube inserted.


Thorax Symmetrical fusiformis, chest retraction (-), icterus(+) HR:

142 bpm, regular, murmur (-). RR: 52x/i, regular.

Abdomen Icterus(+), Rapid turgor, normal peristaltic, liver and spleen

23

unpalpable, umbilical dried.

Extremitie

s


warm, CRT < 3”, icterus (+



hiperbilirubinemia indirect+ unproven sepsis + low birth weight

P Management:

- Placement in incubator, target skin temperature 36,5 – 37,5°C










- Nystatin drop 3x 0,5mL

treatment planning:

- Light therapy for 24 hours

May 18th 2014


O Sens: Alert, Temp: 37,0oC. Anemic (-)Edema (-). Cyanosis (-).Body weight:

2,11 kg.






Nose: O₂ nasal canule inserted

Mouth: orogastric tube inplaced


24

Thorax Symmetrical fusiformis, chest retraction (-), HR: 140 bpm,

regular, murmur (-). RR: 50x/i, regular.


unpalpable, icterus (+).

Extremitie

s


warm, CRT < 3”, icterus (+).




P Management:

- Placement in incubator, target skin temperature 36,5 – 37,5°C











May 19th 2014



2,21 kg.



25


Face: Icterus (+)






regular, murmur (-). RR: 38x/i, regular.icterus (+)


Extremitie

s


warm, CRT < 3”.




P Management:

- Placement in incubator 31 – 33,2°C, target skin temperature 36,5 –

37,5°C











Laboratorium findings

Ca ion/Bil total/Bil Indirect/ Ca/Na/K/P/Cl/Mg : 1,18/9,51/0,46/8,5/135/5,5/

6,2/107/1,99.

CRP qualitative: positive

May 20th 2014

26



2,24 kg.




Face: Icterus (+)






regular, murmur (-). RR: 40x/i, regular.icterus (+)


Extremitie

s


warm, CRT < 3”.




P Management:


37,5°C











27

May 21th 2014

S Dyspnea(+) minimal, icterus(-), suckling effort weak


2,28 kg.




Face: Icterus (+)






regular, murmur (-). RR: 40x/i, regular.icterus (-)


Extremitie

s


warm, CRT < 3”.




P Management:


37,5°C








28




29

DISCUSSION AND SUMMARY

Discussion

30

By TT, 1 days, male, was admitted to perinatology division RSUP HAM

at May 9th 2014 diagnosed with respiratory distress ec Transient tachypnea of

newborn (TTN) + hiperbilirubinemia indirect + unproven sepsis + low birth

weight. The diagnosis of respiratory distress was made based on clinical findings

found in the patient such as tachypnea, grunting,chest retraction and cyanosis

which is the symptom of respiratory distress. This neonates also delivered by

cesarean section with normal gestational age which increases the risk of TTN.

Diagnostic of TTN commonly according to symptoms which

can be seen. This diagnosis is also supported with laboratorium

test and chest x-ray. The common symptom of TTN is a

respiratory distress. Then a laboratorium finding of TTN is usually

mild respiratory acidosis due to mild hypoxemia and

hypercapnia.. Tachypnea can be assessed from counting breath

frequency along one minute when the infant at calm condition.

Dyspnoe can be assessed by looking chest retraction at the lower

chest region when the infant inhaled (epigastrium retraction).

According to the Downes Score, we can classified respiratory

distress based on severity of distress. On chest x-ray, we will find

prominent central marking suggestive of vascular engorgement, moderate

cardiomegaly, increased lung volume, and increased anteroposterior chest

diameter.In this patient, the laboratorium shows metabolic acidosis,

electrolyte imbalance and increased in procalcitonin and CRP.Its

maybe the sign of sepsis. TTN is transient disease that will recover by 72

hour after delivery, but the supportive treatment and the complication treatment

should be done if the symptom is not reduced. This patient was warded in

perinatology ward to support the neonatal ventilation using CPAP . And also this

patient was treated with specific antibiotic to eradicate microorganism that can

cause sepsis. Nutritional support also was given to this patient to increase body

weight.

Summary

31

This paper reports a case of a 1 days, male patient diagnosed wih with

respiratory distress ec Transient tachypnea of newborn (TTN) +

hiperbilirubinemia indirect + unproven sepsis + low birth weight . A

comprehensive treatment with ventilatory support, antibiotics and electrolyte

correction indeed. Adequate nutrition is absolutely supporting child healing from

respiratory distress, and improving his growth and development progress.

REFERENCES

32

1. Ikaria Inc, Understanding Transient tachypnea of Neonates, 2012

2. Kim S.Y., Neonatal respiratory distress: recent progress in understanding

pathogenesis and treatment outcomes, Korean Journal of Pediatrics, Vol 53,

No 1, 2010.

3. Hermansen C.L., Lorah K.N., Respiratory Distress in the Newborn. American

Family Physician,Vol 76,No 7, 2007

4. Kicklighter S.D., Transient Tachypnea of Newborn. Vol 6, No2, Maggio,

2006.

5. Kasim M.S., Respiratory distress in neonates. Lecture Book of Neonatology,

Indonesia Pediatrics Association, 2010.

6. Zaoutis L.B., Chiang V.W., Comprehensive Pediatric Hospital Medicine,

Mosby Inc, 2007

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