Respiratory Distress

of the Newborn
 Learning Outcome
• Mahasiswa memahami pembagian RDN

• Mahasiswa memahami etipatogenesis RDN

• Mahasiswa mampu menjelaskan manifestasi klinis RDN

• Mahasiswa mampu menegakkan diagnosis RDN

• Mahasiswa mampu menjelaskan diagnosis banding RDN

• Mahasiswa mampu melakukan penatalaksanaan RDN

• Mahasiswa mampu menjelaskan prognosis dan komplikasi RDN

 Pendahuluan
• RDN sering terjadi ! 4-6% neonatus

• Diagnosis dini, waktu rujukan & tatalaksana yang tepat !

penting

• Dibagi menjadi

• Surgical cause

• Medical cause

• Faktor maternal berperan dalam etiologi, dan dideteksi

melalui ANC
 Surgical cause

• Tracheo-esophageal fistula

• Diaphragmatic hernia

• Lobar emphysema

• Pierre-Robin syndrome

• Choanal atresia
 Medical cause
• Transient tachypnea of the newborn (TTN)

• Hyaline membrane disease (HMD)

• Meconium aspiration syndrome (MAS)

• Air leak syndrome

• Pneumonia

• Congenital heart diseases

A. Airway Obstructions

Nasal Stenosis Choanal Atresia

Pierre Robin’s Laryngeal

Sequence stenosis or
atresia
Vocal
Cord
Hemangioma
paralysis
Tracheobrochial
Vascular Rings stenosis
B. Disorders of the Chest Wall and Diaphragm

Disorders Congenital
of the chest diaphragmati
wall c hernia
C. Malformation of the Mediastinum
and Lung Parenchyma
Congenital lobar
Congenital cystic emphysema
adenomatoid
malformation

Congenital Pulmonary
pulmonary arteriovenous
cyst malformations

Neoplasms
(teratomas,
mediastinal, Bronchopulmonary
neurablastoma sequestrations
D. Air Leak Syndromes

Pulmonary Pneumomediastinum
interstitial Pneumopericardium
emphysema

Pheumoperitoneum Pneumothorax
 E.Pulmonary Parenchymal and
Vascular Disease
Lung Parenchymal Disease:

● Pneumonia Persistent pulmonary

● Pulmonary edema hypertension of the
● Transient tachypnea of
newborn
newborn
● Meconium
aspiration syndrome

● Hyaline membrane disease

● Congenital alveolar proteinosis
 Cardiac Diseases
A. Cyanotic
● Transposition of great arteries
● Total anomalous pulmonary venous return
● Ebstein’s anomaly
● Tricuspidal atresia
● Severe congestive heart failure
● Pulmonic stenosis
● Tetralogy of Fallot

B. Acyanotic
● Hypoplastic left heart syndrome
● Interrupted aortic arch
● Critical aortic coarctation
● Patent ductus arteriousus
 Neurological Disorder
● Birth Trauma
● Intraventricular hemorrhage
● Meningitis
● Primary seizure disorder
● Obstructed hydrocephalus
● Hypoxic ischemic
encephalopathy
● Infantile botulism
● Spinal Cord injury
● Muscular diseases (myasthenia
gravis, poliomyelitis)
 Other miscellaneous diseases

• Sepsis

• Anemia or polycythemia

• Hypo or hyperthermia

• Hypo or hypernatremia

• Hypoglycemia

• Inborn errors of metabolism

• Maternal medication (magnesium sulfate or opiates) or

drug abuse
 Possible etiology in preterm
Early progressive Hyaline membrane disease

Early transient Metabolic causes, hypothermia

Anytime Pneumonia

Possible etiology in aterm neonates

Early well looking TTN, polycythemia

Early severe distress MAS, asphyxia, malformations

Late sick with hepatomegaly Cardiac

Late sick with shock Acidosis

Anytime Pneumonia
 Evaluasi RDN dengan Skor
Downe
0 1 2
Respiration < 60x/min 60-80x/min > 80x/min
Rate
Retraction No Retraction Mild Retraction Severe
Retraction
Cyanosis No Cyanosis Cyanosis Persistent
relieved by O2 Cyanotic (with
O2)
Air entry Good bilateral Decrease in air No air entry
air entry entry
Grunting No Grunting Audible by Audible without
stethoscope stethoscope
 Penilaian Skor Downe

• <4 : Mild respiratory distress

• 4-7 : Severe respiratory distress

• >7 : Impending respiratory failure

 Respiratory Distress
Syndrome (RDS) or Hyaline
Membrane Disease (HMD)
Hyaline Membrane Disease (HMD)

• HMD adalah gangguan napas pada BBL yang disebabkan

oleh defisiensi Surfactant sebagai penyebab utama

• Bayi prematur ! defisiensi surfactant ! kesulitan bernapas

! respiratory distress ! persisten/progresif salam 48-96 jam
pertama kehidupan

• Avery & Oppenheimer ! HMD sebabkan 3,8 % kematian

prematur dengan BBL 1000-2000 gr.

• Insiden ! berbanding terbalik usia gestasi dan berat lahir

Tertinggi ! Preterm dengan UG 30 – 32 weeks, BBL 1200–
2000 gr
 Risk factors of HMD
Increased risk Decreased risk
Prematurity Chronic intrauterine stress
Male sex Prolonged rupture
Familial predisposition membranes
Cesarean section without Maternal hypertension
labor Narcotic/cocaine use
Perinatal asphyxia IUGR / SGA
Chorioamnionitis Corticosteroids
Hydrops Thyroid hormone
Maternal diabetes Tocolytic agent
Patofisiologi
 Manifestasi Klinis
Anamnesis
• Prematuritas

• Kesulitan bernapas saat lahit

• menjadi lebih berat dalam 6 jam

• riwayat asfiksia intrauterin

• Terdapat perburukan progresif pada X-ray thoraks dan

meningkatnya kebutuhan oksigen

Pemeriksaan fisis
• Takipnu, takikardi, merintih, nasal flaring, retraksi, sianosis
• Foto thorax

• Peripheral air bronchogram

• Uniform reticulogranular
pattern

• Ground glass appearance

 Tatalaksana
A. PREVENTION

• Antenatal corticosteroid

• To enhance fetal pulmonary maturity, using glucocorticoid ! 12

mg betamethasone (recommended) IM 24 h.

• Antenatal ultrasonography ! are accurate assessment of

gestational age & fetal being

• Continuous fetal monitoring ! to signal the need for intervention

when fetal distress is discovered

• Tocolytic agent ! prevent & treat preterm labor

• Assessment of fetal lung maturity (L/S ratio) & phosphatidylglycerol

B. PEMBERIAN SURFACTAN

• Harus ada penyokong ventilasi, digunakan untuk profilaksis dan rescue terapi, mahal

C. RESPIRATORY SUPPORT

• Nasal CPAP, nasopharyngeal CPAP to delay/prevent the need of mechanical

ventilation and endotracheal intubation

• Endotracheal intubation and mechanical ventilation

D. FLUID, NUTRITIONAL SUPPORT, OTHERS

• Parenteral nutrition for an extended period

• Stabilizing blood sugar, temperature, ABC

E. ANTIBIOTIC THERAPY

• Broad spectrum, combination before blood culture result

• Ampicillin-gentamycine, cefotaxime-gentamycin, ceftazidime-amykacyn

F. SEDATION

• Phenobarbital ! to decrease the infant’s activity

Continuous Positive Airway Pressure (CPAP)
• Indikasi CPAP

• Memperbaiki dan meningkatkan FRC paru dan

oksigenasi

• Mencegah kolaps alveolar dan atelectasis

• Meningkatkan daya kembang paru

• Mengurangi usaha napas berlebihan

• Mempertahankan produksi dan fungsi surfaktan

• CPAP digunakan pada pasien dengan distress napas,

penyapihan dari ventilator mekanik.

• Peralatan yang banyak digunakan adalah bubble CPAP

• Flow meter diatur antara 5-10 L/menit

• FiO2 dimulai dengan 40%, diturunkan sampai 21% bila KU

bayi membaik, bila téta terdapat sianosis dapat dinaikkan
hingga 60%

• PEEP awal 7 cmH20, dapat dinaikkan atau diturunkan sesuai

kondisi klinis

• Perhatikan TV, tanda-tanda distress napas, sianosis

• Pengalihan CPAP ke ventilasi mekanik bila:

• FiO2 > 60%

• PaCO2 > 60%

• Asidosis metabolik menetap dengan defisit basa > -8

• Terlihat retraksi nyata

• Sering apnu dan bradikardi

Perbaikan hasil Chest X-ray setelah pemberian surfaktan
Prognosis dan Komplikasi

• The survival of infants with HMD ! improved greatly

• Prognosis for survival with or without respiratory and

neurologic sequelae ! depend on birth weight and
gestational age.

• Komplikasi ! Bronchopulmonary dysplasia (BPD),

Necrotozing enterocolitis (NEC), Intraventricular
hemorrhage (IVH)
Meconium Aspiration
Syndrome (MAS)
 Introduction

• Respiratory distress due to aspiration of meconium by the

fetus in utero or by the neonate during labor and delivery

• Incidence ! 10-26% of all deliveries, mostly in term and

post term deliveries, may represent fetal hypoxemia

• Meconium is the first intestinal discharge of the newborn

infant, composed of epithelial cells, fetal hair, mucus, and
bile.
 Patophysiologi
• Intrauterine stress ! in utero passage of meconium into
amniotic fluid

• The meconium-stained amniotic fluid ! aspirated by the

fetus when fetal gasping/deep breathing movements are
stimulated by hypoxia & hypercapnea

• The meconium in the trachea ! airway obstruction as well

as an inflammatory response ! severe respiratory distress.

• Mother with meconium stained amniotic fluid ! carefully

monitored during labor
 Risk Factors
• Postterm pregnancy

• Preeclampsia-eclampsia

• Maternal hypertension

• Maternal diabetes mellitus

• Abnormal fetal heart rate

• Intrauterine growth retardation

• Abnormal biophysical profile

• Oligohydramnion

• Maternal heavy smoking

• Chronic respiratory/cardiovascular
disease
 Clinical Presentation
• Meconium stain amniotic fluid before
birth

• Meconium staining of neonate after

birth

• Varying degree of respiratory

distress; barrel chest; audible rales

• Persistent pulmonary hypertension of

the newborn

• Pneumotorax (10%-20% infants with

MAS)
A. General features

• Infant ! Postmaturity

• Respiratory distress at
birth / in the transition
period

• Perinatal asphyxia ! they

may have respiratory
depression with poor
respiratory effort &
decreased muscle tone
B. Airway obstruction

• Apnea, gasping respiration, cyanosis, poor air exchange

• Later, the meconium is driven down to more distal airways, the

smaller airways are affected, resulting in air trapping and
scattered atelectasis

C. Respiratory distress

• Tachypnea, nasal flaring, intercostal retraction, increased AP

diameter of the chest and cyanosis.

D. Other pulmonary abnormalities

• Decreased air exchange, rales, rhonchi/ wheezing

 Diagnosis
• Clinical presentation

• Laboratory ! ABG !
metabolic acidosis

• Chest radiograph:

• Hyperinflation of the
lung fields and
flattened diaphragms

• Irregular patchy
infiltrates

• Pneumothorax/
pneumomediatinum
 Management
• Prenatal management
• Identification of high-risk pregnancy

• Monitoring of fetal heart rate during labor

• Delivery room management

• Placed under radiant warmer ! Suction infant’s mouth,

pharinx and nose as soon as complete delivered

• Suction the hypopharinx to clear any residual meconium

• Depressed infants (depressed respiration, HR < 100 beat/

min, poor muscle tone) ! tracheal visualization and
suctioning should be performed ! Neonatal Resuscitation
• Respiratory management
• Supplemental oxygen

• Mechanical ventilation

• General management
• Antibiotics, same in all RDN

• Empty the stomach contents to avoid further aspiration

• Correction of metabolic abnormalities e.g. hypoxia,

acidosis, hypoglycemia, hypocalcemia and
hypothermia

• Surveillance for end organ hypoxic/ischemic damage

(brain, kidney, heart and liver)
Transient Tachypnea of
the Newborn (TTN) or
Wet Lung
 Introduction

• TTN is a benign disease of near-term, term or large

premature infants who have respiratory distress shortly
after delivery

• It usually resolves within 3-5 days

• Usually without severe complication

 Risk Factors
• Elective cesarean section delivery

• Male sex

• Macrosomia

• Excessive maternal sedation

• Prolonged labor

• Birth asphyxia

• Breech delivery

• Infant of diabetic mother

• Prematurity

• Very low birth weight neonates

 Patophysiology
• Delayed resorption of fetal lung fluid
• Tachypnea and retraction

• Infants delivered by elective cesarean section are at

risk because of lack of the normal vaginal thoracic
squeeze, which forced lung fluid out

• Pulmonary immaturity
• Mature L/S ratio but negative phosphatidylglycerol
(completed lung maturation)

• Mild surfactant deficiency

 Clinical Presentation

• Usually near term, term, or large and premature and

shortly after delivery has tachypnea (> 60x/min up to
100-120x/min)

• Grunting

• Nasal flaring

• Rib retraction

• Varying degrees of cyanosis

 Diagnosis
• Laboratory :

• L/S ratio in amniotic fluid,

arterial blood gas, CBC

• Chest X-ray :

• Hyperexpansion of the lungs

• Prominent perihilar streaking

• Mild/moderately enlarged heart

• Depression (flattening) of
diaphragm

• Fluid in the minor fissure

• Prominent pulmonary vascular

markings
 Management
• O2

• Antibiotics ! initially broad spectrum

• Feeding :

• RR > 60x/min ! not be fed by mouth

• RR < 60x/min ! oral feeding is permissible

• RR 60 – 80 x/min ! feeding should be by nasogastric

tube

• RR > 80x/min ! Intravenous nutrition

Prognosis and Complication

• TTN is self-limited

• Usually lasts only 2-5 days

• No risk of further pulmonary dysfunctions

Apnea and Periodic
Breathing
 Introduction

• Apnea is the absence of respiratory gas flow for a period

of 20 seconds or greater or of shorter duration if
associated with bradycardia or significant desaturation

• Preterm baby are prone to episodes of apnea, which are

more frequent in very small babies (less than 1,5 kg at
birth or born before 32 weeks gestation) but they become
less frequent as the baby grows.
Classification of Apnea
1. Central apnea of CNS origin and is characterized by the
absence of gas flow with no respiratory effort

2. Obstruction apnea is continued by respiratory effort not

resulting in gas flow

3. Mixed apnea is combination 1 & 2

• Periodic breathing ! three or more periods of apnea

lasting within 20 seconds period of otherwise normal
respiration, is also common in newborn period
 Patophysiology

• Immaturity of respiratory control

• Sleep-related response

• Muscle weakness

• All of these factors point to an immature respiratory

control mechanism in the preterm infant
Pathologic state which cause apnea:

• Hypothermia and hyperthermia

• Metabolic disturbances

• Sepsis

• Anemia

• Hypoxemia

• CNS abnormalities

• Necrotizing enterocolitis

• Drug withdrawal and drug effects

• Gastroesophageal reflux
Clinical Presentation

• Apnea within 24 h after delivery

• Apnea after the first 24 h of life

Physical Presentation

• Lethargy

• Hypothermia/hyperthermia

• Cyanosis

• Respiratory effort
 Diagnosis

• Clinical and physical presentations

• Chest X-ray

• Atelectasis

• Pneumonia

• Air leak
 Management
• Oxygen

• CPAP

• Pharmacologic therapy

• Theophylline

• Caffeine

• Mechanical ventilation

• If apnea is severe and is associated with hypoxia/significant

bradycardia ! intubation and mechanical ventilation may be
indicated
Aminophylline
• Neonatal Apnea

• Loading dose ! 6 mg/kgBW/dose IV

• Maintenance dose

• ≤ 1 kg 24 hrs after loading

• 1 kg 12 hrs after loading

• IV :

• Age ≤ 7 days 2.5 mg/kg/dose 12 hrly

• Age 8-14 days 3 mg/kg/dose 12 hrly

• Age >14 days 4 mg/kg/dose 12 hrly

Caffeine Citrate

• Loading dose

• IV, Oral ! 20 mg/kg

• Maintenance dose

• (commence 24 hrs after loading dose)

• IV, Oral ! 5 mg/kg/daily

• Maintenance dose can be increased to a maximum of

10 mg/kg/day
 Prognosis

• The best indicator for prognosis is depend on the CAUSE

• Apnea of prematurity has an excellent prognosis, whereas

that associated with IVH has a poorer prognosis
Pneumothorax
• Respiratory and cardiovascular deterioration

• Increase respiratory distress

• Cyanosis

• Bradycardia or tachycardia

• Evaluate for:

• Chest asymmetry

• Shift in point of maximum impulse (Punctum maximum)

• Hypotension

• Poor peripheral pulses, mottled appearance

• Flattened or decreased QRS complex on ECG/dampened

arterial waveform
• Chest X-ray ! if time allows

• Anteroposterior view

• If still unsure lateral decubitus x-ray

• Transillumination ! for rapid detection

• False positive ! skin edema, subcutaneous air,

pneumomediastinum, severe pulmonary interstitial
emphysema

• False negative ! thick chest wall, darkly pigmented

skin, room too light, weak transilluminator light source