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Kepada Yth.
Perinatology Unit
RESPIRATORY DISTRESS EC TRANSIENT TACHYPNEA OF
NEWBORN
Presenter
Day/Date
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. 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).
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.
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
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 Womens 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.
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.
Respiratory Distress
Definition
Respiratory distress is the condition where the respiratory effort is increasing
from the normal. It is characterized by:
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 obstruction
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.
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:
Evaluation
Total score
13
4-5
6
Diagnosis
Mild respiratory distress
Moderate respiratory distress
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
Prematurity,
respiratory
distress
syndrome,
meconium
aspiration
b) Physical examination
On physical examination, we will find clinical sign of respiratory distress such
as:
Grunting
Cyanosis
Retraction
Scaphoid abdomen
c) Laboratorium findings
a) Blood Gas Analysis
in
bicarbonates
ion
result
from
metabolic
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.
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 amiloridesensitive Na + transport. These results suggest that infants with neonatal RDS
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.
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
10
CASE REPORT
Name
: by TT
Age
: 1 day
Sex
: Male
Date of Admission
Chief Complaint
: dyspnea
History
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
:-
:-
:-
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 :
-
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:
Pulse 164 bpm, regular, adequate pressure and volume, warm, CRT < 3,
Urogenital:
Male, anus (+) within normal limit.
12
Value
Normal Value
14,00 gr%
42,20 %
4,06 x 106 /mm3
10,46 x 103 /mm3
100.000 /mm3
103,90 fl
36,00 pg
34,60 gr%
15,80 %
0,4/ 0,2 / 62,5 / 24,9 /
12,00
Value
Normal Value
7,277
32,6 mmHg
183,7 mmHg
14,9 mmol/L
15,9 mmol/L
- 10,9
99,1 %
7,35 7,45
38 42
85 100
22 - 26
19 - 25
(-2) (+2)
95 - 100
56,00
<200
6,8 mg/dL
140 mEq/dL
4,1 mEq/dL
6,2 mEq/dL
111 mEq/dL
2,63 mEq/dL
8,4 10,8
135 155
3,6 5,5
5,0 9,6
96 - 106
1,2 1,8
Positive
38,44 mg/dL
< 0,005
13
Differential Diagnosis:
-
Working Diagnosis:
Management:
-
Diagnostic Planning:
-
Septic workup
Glucose ad random
Chest Xray
14
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
Neck
Thorax
Abdomen
Extremitie
154 bpm, regular, murmur (-). RR: 65x/i, reguler, rales (-)
Soeple, normal peristaltic, liver and spleen unpalpable,
Pulse 154 bpm, regular, adequate pressure and volume,
s
warm, CRT < 3,
Genital
Male, within normal limit.
- Respiratory Distress ec DD/ Transient Tachypnea of Newborn
Hyaline Membrane Disease
Suspect sepsis
Low Birth Weight
CPAP with FiO 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
Inj. Ceftazidine 120mg/12 hour/ IV (D1)
Lab Result:
Hb/ He/ L/ T : 14,6/42,2/ 10460/ 100 000
pH/pCO/pO/HCO/TCO/BE/SO
7,27/ 32,6/ 183,3/ 14,9/ 15,9/ -10,9/ 99,1
15
Neck
Thorax
Abdomen
Extremitie
150 bpm, regular, murmur (-). RR: 83x/i, reguler, rales (-)
Rapid turgor, normal peristaltic, liver and spleen unpalpable,
Pulse 150 bpm, regular, adequate pressure and volume,
s
warm, CRT < 3,
Genital
Male, within normal limit.
- Respiratory Distress ec DD/ Transient Tachypnea of Newborn
Hyaline Membrane Disease
- Suspect sepsis
- Low Birth Weight
Management:
-
16
Neck
Thorax
Abdomen
Extremitie
148 bpm, regular, murmur (-). RR: 60x/i, reguler, rales (-)
Rapid turgor, normal peristaltic, liver and spleen unpalpable
Pulse 148 bpm, regular, adequate pressure and volume,
s
warm, CRT < 3.
Genital
Male, within normal limit.
- Respiratory Distress ec DD/ Transient Tachypnea of Newborn
Hyaline Membrane Disease
- Suspect sepsis
- Low Birth Weight
Management:
CPAP with FiO 21% PEEP 5 ,O 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
17
Mouth: OGT(+)
Within normal limit
Symmetrical fusiformis, chest retraction (+) epigastic and
suprasternal, HR: 148 bpm, regular, murmur (-). RR: 60x/i,
Abdomen
Extremitie
A
P
regular.
normal peristaltic, liver and spleen unpalpable,
Pulse 148 bpm, regular, adequate pressure and volume,
s
warm, CRT < 3,
Genital
Male, within normal limit.
- Respiratory distress ec Transient tachypnea of Newborn + icteric
neonatorum + susp sepsis + Low birth weight
Management:
-
18
Abdomen
Extremitie
A
P
s
warm, CRT < 3.
Genital
Male, within normal limit.
- Respiratory distress ec Transient tachypnea of newborn +
hiperbilirubinemia indirect+ susp sepsis + low birth weight.
Management:
- Infant radiant warmer target skin temperature 36,5- 37,5C.
- CPAP FiO 21%, PEEP 5, flow 5L/i
- 24 hour light therapy
- Total fluid requirement 150mL/kg/day = 360mL/day
o Parenteral 70mL/kg/day = 168mL/day
o IVFD D5% NaCl 0,225%(430mL), D40%(70mL), KCl 10mEq + Ca
Gluconas 10mL = 7gtt/i micro
o Enteral 80mL/kg/day = 192mL/day
o Diet PASI/ASI 10mL/2hour/OGT
- Inj. Ceftazidine 120mg/12hour/IV (D5)
- Inj. Gentamisin 12mg/36hour/IV (D5)
- Nystatin drop 3 x 0,5mL
Neck
Thorax
Abdomen
Extremitie
A
P
Genital
Male, within normal limit.
- Respiratory distress ec Transient tachypnea of newborn +
hiperbilirubinemia indirect+ susp sepsis + low birth weight.
Management:
- Infant radiant warmer target skin temperature 36,5- 37,5C.
- CPAP FiO 21%, PEEP 5, flow 8L/i
- Total fluid requirement 150mL/kg/day = 360mL/day
o Parenteral 60mL/kg/day = 129mL/day
o IVFD D5% NaCl 0,225%(430mL), D40%(70mL), KCl 10mEq + Ca
Gluconas 10mL = 7gtt/i micro
o Enteral 90mL/kg/day = 194mL/day
o Diet PASI/ASI 16mL/2hour/OGT
- Inj. Ceftazidine 120mg/12hour/IV (D6)
- Inj. Gentamisin 12mg/36hour/IV (D6)
- Nystatin drop 3 x 0,5mL
A
P
Neck
Thorax
Abdomen
Extremitie
s
warm, CRT < 3.
Genital
Male, within normal limit.
- Respiratory distress ec Transient tachypnea of newborn +
hiperbilirubinemia indirect+ susp sepsis + low birth weight.
Management:
- Infant radiant warmer target skin temperature 36,5- 37,5C.
- O nasal cannule low flow 0,5L/i
- Total fluid requirement 150mL/kg/day = 360mL/day
o Parenteral 50mL/kg/day = 120mL/day
o IVFD D5% NaCl 0,225%(430mL), D40%(70mL), KCl 10mEq + Ca
Gluconas 10mL = 5gtt/i micro
20
A
P
Neck
Thorax
Abdomen
Extremitie
s
warm, CRT < 3, icterus (+
Genital
Male, within normal limit.
- Respiratory distress ec Transient tachypnea of newborn +
hiperbilirubinemia indirect+ unproven sepsis + low birth weight
Management:
- Placement in incubator, target skin temperature 36,5 37,5C
- O nasal cannule low flow 0,5L/i
- Total fluid requirement 150mL/kg/day = 360mL/day
o Parenteral 40mL/kg/day = 95mL/day
o IVFD D5% NaCl 0,225%(430mL), D40%(70mL), KCl 10mEq + Ca
Gluconas 10mL = 4gtt/i micro
o Enteral 110mL/kg/day = 264mL/day
o Diet PASI/ASI 22mL/2hour/OGT
- Inj. Ceftazidine 120mg/12hour/IV (D8)
- Inj. Gentamisin 12mg/36hour/IV (D8)
21
A
P
Neck
Thorax
Abdomen
Extremitie
icterus (+).
Pulse 140 bpm, regular, adequate pressure and volume,
s
Genital
22
A
P
Neck
Thorax
Abdomen
Extremitie
s
warm, CRT < 3.
Genital
Male, within normal limit.
- Respiratory distress ec Transient tachypnea of newborn +
hiperbilirubinemia indirect+ unproven sepsis + low birth weight
Management:
-
37,5C
- O nasal cannule low flow 0,5L/i
- Total fluid requirement 150mL/kg/day = 360mL/day
o Parenteral 30mL/kg/day = 72mL/day
o IVFD D5% NaCl 0,225%(430mL), D40%(70mL), KCl 10mEq + Ca
Gluconas 10mL = 3gtt/i micro
o Enteral 120mL/kg/day = 288mL/day
o Diet PASI/ASI 24mL/2hour/OGT
- Inj. Ceftazidine 120mg/12hour/IV (D10)
- Inj. Gentamisin 12mg/36hour/IV (D10)
- Nystatin drop 3x 0,5mL
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
23
A
P
Neck
Thorax
Abdomen
Extremitie
s
warm, CRT < 3.
Genital
Male, within normal limit.
- Respiratory distress ec Transient tachypnea of newborn +
hiperbilirubinemia indirect+ unproven sepsis + low birth weight
Management:
-
37,5C
- O nasal cannule low flow 0,5L/i
- Total fluid requirement 150mL/kg/day = 360mL/day
o Parenteral 30mL/kg/day = 72mL/day
o IVFD D5% NaCl 0,225%(430mL), D40%(70mL), KCl 10mEq + Ca
Gluconas 10mL = 3gtt/i micro
o Enteral 120mL/kg/day = 288mL/day
o Diet PASI/ASI 24mL/2hour/OGT
- Inj. Ceftazidine 120mg/12hour/IV (D11)
- Inj. Gentamisin 12mg/36hour/IV (D11)
- Nystatin drop 3x 0,5mL
24
A
P
Neck
Thorax
Abdomen
Extremitie
s
warm, CRT < 3.
Genital
Male, within normal limit.
- Respiratory distress ec Transient tachypnea of newborn +
hiperbilirubinemia indirect+ unproven sepsis + low birth weight
Management:
-
37,5C
- O nasal cannule low flow 0,5L/i
- Total fluid requirement 150mL/kg/day = 360mL/day
o Parenteral 20mL/kg/day = 48mL/day
o IVFD D5% NaCl 0,225%(430mL), D40%(70mL), KCl 10mEq + Ca
Gluconas 10mL = 2gtt/i micro
o Enteral 130mL/kg/day = 312mL/day
o Diet PASI/ASI 26mL/2hour/OGT
- Inj. Ceftazidine 120mg/12hour/IV (D12)
- Inj. Gentamisin 12mg/36hour/IV (D12)
- Nystatin drop 3x 0,5mL
25
26
respiratory
acidosis
due
to
mild
hypoxemia
and
27
Summary
This paper reports a case of a 1 days, male patient diagnosed wih with
respiratory
distress
ec
Transient
tachypnea
of
newborn
(TTN)
+
. A
28
REFERENCES
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