CASE REPORT:

RESPIRATORY DISTRESS SYNDROME

IN NEONATUS

Ayu Naniza Peri, S.Ked M. Reyhan Ahza Hamidy, S.Ked

Gebby Puspita Angraini, S.Ked Wiwit Asari, S.Ked

Supervisor:
dr. Zulfikri, Sp. A

PEDIATRIC DEPARTMENT
FACULTY MEDICINE OF RIAU UNIVERSITY
2020
 INTRODUCTION

• Respiratory Distress Syndrome (RDS) is common occurs in neonatus

• Many risk factors can cause RDS in neonatus
• In develop country (USA) incidence of RDS 1% or 20,000-30,000 babies
die because of RDS
• 50% incidence of RDS occurs in preterm newborn
• In Indonesia, 950,000 babies born with low birth weight -> 150,000
babies suffer from RDS

Wartenberg D, et. al. 2008, Permono B, et al. 2005, Tehuteru ES. 2015, Ludwig H, et al. 1997, and Lowe EJ. 2005.
 LITERATURE REVIEW
DEFINITION
Respiratory distress syndrome (RDS) / Hyaline Membrane Disease (HMD) is
a lung disorder that occurs in preterm newborn due to lung surfactant
deficiency associated with immaturity of the fetal lungs.

EPIDEMIOLOGY
• In develop country (USA) incidence of RDS 1% or 20,000-30,000 babies
die because of RDS
• In Indonesia, 950,000 babies born with low birth weight -> 150,000
babies suffer from RDS
Monintja HE. Masalah umum sindrom gawat nafas pada neonatus. Dalam: Monintja HE, Aminullah A, Boedjang RF, Amir I, penyunting.. FKUI.
2013.
 LITERATURE REVIEW
RISK FACTOR

• Premature
• Low Birth Weight
• Male
• Sectio Caesaria Operation
• Antepartum infection

Kim J, Lee M, Hwan Y. Risk factor for respiratory distress syndrome in full term neonates. Yeungnam Univ J Med. 2018
 LITERATURE REVIEW
PATHOPHYSIOLOGY
Deficiency of the
surfactant substance
found in PMH causes the
ability of the lung to
maintain its stability
disturbed. This results in
disruption of the baby's
lung function after birth.

Abdul L, Partogi M, Antonius P, Sukman PT. Penyakit membran hyalin.. 2008.

 LITERATURE REVIEW
CLINICAL MANIFESTATION DIAGNOSIS

• Tachypnea • Clinical symptoms

• Nostril breath • Physical examination
• Chest Retraction • Investigations (Radiology)
• Grunting

West JB. Respiratory Physiology: The Essentials. Baltimore, MD:Williams& Wilkins; 2012.
 LITERATURE REVIEW

RADIOLOGY FINDINGS
 LITERATURE REVIEW
TREATMENT
Non
Respiratory Respiratory

Prevent
Clean the airway
Hipotermia

Ensuring
Prevent adequate
Hypoglicemia respiration and
circulation

Mathai S, Raju C, Kanitkar C. Management of respiratory distress in the newborn. MJAFI. 2007;63.hlm.269-72.
 LITERATURE REVIEW

COMPLICATION PROGNOSIS

• Short-term complication • Prognosis depends on the cause,

• Long-term complication the presence of dysfunction of
other organs, age and chronic
disease sufferers

Rogayyah. Faktor-faktor yang berhubungan dengan kejadian Respiratory Distress Syndrome. 2016
 CASE REPORT
IDENTITY
• Name : CA's baby
• Age : 10 minutes old
• MR number : 01034381
• Date of admission RSUD AA : 22nd January 2020
• Date of admission (IPN) : 22nd January 2020
• Date of examination : 23th January 2020
• Patient status : Alive

CHIEF COMPLAINT:
Neonatus 10 minutes old entered from the OK IGD of Arifin Achmad regional hospital with
respiratory distress problems.
 HISTORY OF PRESENT ILLNESS

• Neonatus was born on January 22th, 2020 at 13:20 WIB in the OK IGD
of Arifin Achmad Regional Hospital by Sectio Caesarea on indications
of uterine myoma multiple and hypertension in pregnancy.
• Neonatus immediately crying, good muscle tone, full term, active
movements. APGAR value in the first minute was 8 and in the fifth
minute was 9.
• Neonate was given routine treatments such as Neo K injection, eye
ointment and anthropometric measurements. At the age of 6
minutes, neonate was grunting, severe chest retraction, respiratory
rate 60 times / minute and there was peripheral cyanosis (Down
Score 7).
 HISTORY OF PRESENT ILLNESS

• Neonatus was born on January 22th, 2020 at 13:20 WIB in the OK IGD
of Arifin Achmad Regional Hospital by Sectio Caesarea on indications
of uterine myoma multiple and hypertension in pregnancy.
• Neonatus immediately crying, good muscle tone, full term, active
movements. APGAR value in the first minute was 8 and in the fifth
minute was 9.
• Neonate was given routine treatments such as Neo K injection, eye
ointment and anthropometric measurements. At the age of 6
minutes, neonate was grunting, severe chest retraction, respiratory
rate 60 times / minute and there was peripheral cyanosis (Down
Score 7).
 CONT…..

• Neonatus was planned to be transferred to the Neonatal Care

Installation (IPN) to receive further treatment. Neonatus was
brought to IPN by using nasal oxygen 1 L / min.
• Neonatus arrived at IPN at the age of 10 minutes with still grunting,
severe chest retraction, cyanosis, with down score 8, the
temperature was 34.6 C, O2 saturation was 45%. Neonatus was
placed in infant warmer, then intubation was performed with ETT
No. 3 and Orogastric Tube (OGT) No. 5, and oxygen saturation was
75%.
 CONT…..

• Neonatus was fasted and D10% infusion of 5,8 cc per hour was
performed. Neonatus was placed in the NICU room in an incubator.
At the age of 1 hour, neonatus was had blood glucose check and the
results was 75 mg/dL, then blood routine tests and blood gas
analysis was done.
• Neonatus was planned to have a baby gram examination at the age
of 6 hours and a Septic Marker examination at the age of 12 hours
for infection screening.
 PREGNANCY HISTORY

• Ante natal care (ANC) was 7 times to a Obstetric and Gynecologic specialist.
 1st trimester = 2 times
 2ndtrimester = 2 times Fetus in good condition
 3rd trimester = 3 times

• Diagnosis of maternal pregnancy was G1P0A0H0 with gestational age 33-34

weeks, oligohidramnion, multiple uterine myoma.

• At 8th – 12th and 33rd week gestational age : Vaginal bleeding for 1 month
• At 32nd week gestational age : Hypertension
• There is no fever and vaginal discharge history
 PHYSICAL EXAMINATION

Conciousness : Alert

General condition :
Alert, cyanosis, weak tonic, grunting, warm acral.

Vital sign:
HR : 160 bpm, reguler, strong
RR : 90 times/minute
T : 34,6OC
Warm acral, CRT <2 second
 GROWTH STATUS

Birth weight : 1750 gr

Current weight : 1725 gr
Birth length : 44 cm
Head circumference : 30 cm
Chest circumference : 27 cm
Upper arm circumference : 8 cm
Abdominal circumference : 24 cm
 PHYSICAL EXAMINATION

Central Nervous System

Cyanosis skin, baby was alert, isokor pupil, pupillary reflex (+/+)

Head
Normal fontanella, normal suture, central sianosis (-), low set ear (-)

Respiratory System
Respiratory rate 90 times/min, severe chest retraction, grunting (+), vesikuler
breath (+/+), Down Score 8
 PHYSICAL EXAMINATION

Cardiovascular system :
Heart rate 160 bpm, S1 S2 reguler, murmur (-), CRT < 2 second

Gastrointestinal system :
Redness abdomen skin, abdominal circumference 24 cm, mass (-), peristaltic (+) 8
times/min, patent anus.

Genitalia :
Male, congenital anomaly (-), testis (+/+)

Extremity :
Symmetrical extremity, Congenital Talipes Equinovarus (CTEV) (-), polydaktily (-), normal
pelvic and arm joints, spina bifida (-).
 PHYSICAL EXAMINATION

Congenital anomaly (-), labor

injury (-), neuromuscular
maturity 12, physical maturity
11. Ballard score : 23
 PHYSICAL EXAMINATION

Important Things From Mother

• Mother with a history of uterine myoma
• Hypertension in pregnancy
• Oligohidramnion
• ANC history was 7 times.

Important Things From Baby

• Male baby with 33-34 weeks' gestation
• Birth weight 1750 grams
• Temperature 34,6oC
• Respiratory Distress (Down Score 8)
 WORKING DIAGNOSIS

• NKB-SMK-BBLR
• Respiratory Distress Syndrome
• Hipotermia
 INITIAL TREATMENT

• Treated in Neonatal Care Installation (NICU)

• Keep warmth (take to an incubator)
• Intubation (ETT Number 3)
• Ventilator with P A / C mode (50% FiO2, PIP 15, IT 0.35, PEEP 6)
• IVFD D10%, 80cc / kg / day → 5.8 cc / hour
• NPO
• Ampicillin sodium-sulbactam (picyn) 130 mg / 12 hours
• Gentamicin 8mg / 36h.
 EXAMINATION

• Routine blood tests, CRP, IT Ratio, blood culture

• Blood glucose
• Rontgen babygram
• Blood gas analysis
 LABORATORY FINDINGS

Routine Blood Tests Blood Gas Analysis

(23/01/2020) (23/01/2020)

• Hb: 15,6 gr/dL • pH : 7,08 (L)

• Leukocyte: 15.460 /mm3 • pCO2 : 76,9 mmHg (H)
• Hematokrit: 46,8% • pO2 : 46,6 mmHg(L)
• Trombocyte: 189.000/mm3 • HCO3 :22,5 mM
• Blood Sugar: 149 mg/dL • BE :-9,1 mM
• CRP Kuantitatif : 27,4(H) • Result : Respiratory Acidosis
RADIOLOGY FINDINGS

Result : cor and

pulmonal within
normal limit
 DIAGNOSIS

• NKB-SMK-BBLR
• Respiratory Distress Syndrome (RDS)
• Hipotermia
FOLLOW UP
Subject 2 3 4 5 6 7 8 9 1
0
1
1
1
2
1
3
1
4
1
5
1
6
1
7
1
8
1
9
2
0
21

Increase work of
breathing
Seizure
Fever
BAK
BAB
Slem
Pale
Flebitis
Lesion in gluteal
Right Eye Secrete
FOLLOW UP
300

250

200

150

100

50

0
D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 D15 D16 D17 D18 D19 D20 D21

Heart rate Respiration rate Temperature (F) Weight (dag) Calori

FOLLOW UP
Date Supporting Examniation Date Supporting Examination

23/01/2020 CRP : 27.4 mg/dL 28/02/2020 Hb :9.7g/dL

Day 2 Day 7
Blood Gas Analysis
-pH : 7,29
-pCO2 : 55,9 mmHg 3/02/2020 Hematology
-pO2 : 187,6 mmHg Day 13 -Hb : 17.8 g/dL
-HCO3- : 27mM -Leukocyte : 12950/UL
-BE : -0.6 mM -Trombocyte : 78.000/UL
Blood Culture
Thorax Rontgen -Result : Serratia marcescens
Cor : Within normal limit
Pulmo : Within normal limit

11/02/2020 -Hb: 13.9

Da 21 -Leukocyte : 12.000/uL
-Trombocyte : 315.000/uL
-Eritrocyte : 4.41 juta/uL
24/01/2020 -pT : 15.2 Sec -Hematokrit: 41.3%
-CRP : 1.8 mg/dl
Day 3 -INR : 1.07
-APTT : 32.8 Sec
FOLLOW UP
THERAPY 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Ventilator P A/C
NCPAP
Suction
D10% + Ca 10 cc
D10% 1/5NS + Kcl + Ca
Amino glyserin 10% 3gr
ASI/Susu formula
Midazolam
Pyicin 130mg/12jam
Gentamicin 8mg/36jam
 FOLLOW UP
2 3 4 5 6 7 8 9 1 1 1 1 1 1 1 1 1 1 2 21
THERAPY 0 1 2 3 4 5 6 7 8 9 0

Meropenem 75mg/8jam
Amikasin 15mg/18jam
Gammaras 50cc
Tranfusi PRC 2x30 cc
Tf trombosit 3x34cc
Kalnex 20mg/12 jam
Myco-z 1x3
Polygran 1tetes/6ajm
Fenton Preterm
Growth Chart
 DISCUSSION

CASE
Diagnosis:
• NKB (33-34 weeks) - SMK - LBW (1750 gram)
• Respiratory Distress Syndrome (Down 8 score)

THEORY
• Prematurity and immature lecithin / sphingomielin (L / S) ratio
• Not enough surfactant levels
• Risk factors (LBW, maternal diabetes, hypothermia, asphyxia, male sex, birth
by cesarean section)
 DISCUSSION

CASE
• Respiratory failure (PCO2 76.9 mmHg, pH 7.08, PaO2 45 mmHg and SO2 45%)
• Initial management: Intubation (ETT no. 3, ventilator (P A / C) RR = 50, IT =
0.35, PIP = 15, PEEP = 6 and FiO2 = 50%)

THEORY
• Intubation indications: respiratory failure (PCO2> 60 mmHg, pH <7.2, and
PaO2 <50mmHSO2 <100%)
• Martin Britos's Researcher in 2011: in preterm neonatus PaO2 levels to be
obtained is 50-80 mmhg and SpO2 levels 88-92%
 DISCUSSION

CASE
• The baby looks uncomfortable (A lot of procedure makes the baby uncomfortable)
• Management: midazolam 1cc / hour
• Evaluation: babies appear more comfortable, have regular breathing, lung expansion to
thoracic 8 - 9, and O2 saturation is achieved

THEORY
• Midazolam as sufficient sedation during mechanical ventilation
• Taddio A study in 2017: midazolam dose for neonates that given mechanical ventilation is
30-60 mcg / kg / hour
 DISCUSSION

CASE
• Neonatus with LBW (1750 grams), preterm (33 weeks) and ventilators
intervention, quantitative CRP 27.4 mg / L.
• Empirical Therapy: Ampicillin sulbactam (picyn) 130 mg / 12 hours and gentamicin
8 mg / 36 hours

THEORY
• Antibiotics given if there are at least 2 risk factors for sepsis
• Aline Fuchsa's 2016 study: penicillin, gentamicin and ceftriaxone are
recommended in the treatment of sepsis in nenonatus and children 48-72 hours
while waiting for the results of culture.
 DISCUSSION

CASE
• Based on the results of blood culture, there is a growth of Serratia mersescens.
• Neonatus was given 75mg / 8h of Meropenem antibiotics and 15mg / 12hm of Amikacin
according to culture and sensitivity results.

THEORY
• Setyadewi Lusyati et al in her study that neonatal sepsis is dominated by gram-negative
bacteria (68.3%) with the most species being Serratia marcescens (85.1%) originating
from nosocomial infections.
• High sensitivity is found in the antibiotics meropenem, piperacillin-tazobactam,
cefoperazon-sulbactam, ciproflosaksin, and phosphomycin.
 DISCUSSION

CASE
• Conjunctivitis (eye secret with redness of the sclera of the right eye
• Management: polygran 1 drop / day

THEORY
• Neonatus has immature lacrimal duct system, immature immune system,
conjunctival colonization can occur during neonatal care.
 DISCUSSION

CASE
• Neonatus has pale, tachycardia symptoms with hemoglobin (Hb) level of 9.7
gr / dl, low platelets.
• Management: 2x30cc PRC transfusion and 3x34cc Platelet transfusion.

THEORY
• Indications PRC transfusion is Hb <7.0 g / dl or there are signs of mild anemia
and symptoms such as tachycardia or inadequate weight gain, transfusion
can be given at Hb levels <10 g / dl with transfusion dose 20ml/kg
 DISCUSSION

CASE
• Neonatus nutrition is given through intravenous fluids, breast milk and formula milk
• The average growth of head circumference is 0.67 cm / week, body length is 0.83, and
body weight is 11.7 grams / day
• The baby is sick

THEORY
• The average head circumference growth 0.5 - 0.8 cm/week, body length 0.8
-1 cm/week and body weight 15 gram/day
Thank You 