Respiratory distress of newborn

(RDN) adalah permasalahan bayi

baru lahir yang paling sering
dihadapi dokter anak di lapangan.

Sering kali, hanya dengan radiologi
konvensional, dokter anak sudah
dapat menegakkan diagnosis RDN.
Bila diagnosis RDN pada bayi
dapat ditegakkan sejak dini, maka
penanganan kasus tersebut dapat
dilakukan secara cepat dan tepat.
Pneumothorax occurs at
any ages, including
neonates and children.
This condition is medical
emergency that can cause
death, especially in
children.
There is much national and
international controversy
surrounding the right
initial treatment of
pneumothorax
A-14 years and 8 month girl,
presented to pediatric dept.
Wahidin Sudirohusodo Hospital
on November 13
th
, 2012
with main complaint was
shortness of breath
Aloanamnesis: From her mother
Main complaint: shortness breath (sudden onset)
experienced since six hours prior to the admission.

Sudden onset chest pain
Paroxysmal cough for one week
Frequent cough for three month but no dyspnea
No fever and seizure
History of frequent fever for three months
Nausea and vomiting two times
Her appetite was decreased
Defecation and micturition were normal
Body weight decreased for the last three months
Bed time sweating for the last one month
Contact with adult tuberculosis patients was denied
History of chest trauma was denied
There was no contact history with suddenly died poultry
General condition:
Severely ill, under nourish, and conscious child (GCS 15).
Vital sign:
BP 90/60 mmHg. PR 120x/min. RR 60x/min. BT 37.8
0
C
Body weight 13 kg. Body length 96 cm.

Inspection :
distressed and sweating. No pale and cyanotic, nostril breathing.
Assymetrical chest movement, retraction on suprasternal & subcostal
Palpation :
found crepitations on the left lung.
Percussion :
hyper-resonance over the collapse lung.
Auscultation :
Breath sounds are reduced or absent over the affected area (left side).
Crackles are found on the right lung, there is no wheezing appearance.
Complete blood count:

WBC 9.560 /mm
3

RBC 4.54 x10
6
/mm
3

HGB 12.7 g/dl
3

HCT 38.3 %
MCV 84.4 fl
MCH 28.0 pg
MCHC 33.2 g/dl
PLT 317.000 /mm
3

Blood gas analysis:
pH 7.454 Result:
PO
2
61.2 mmHg Fully compensated
PCO
2
30.8 mmHg respiratory alkalosis.
SO
2
92.2 %
HCO
3
21.2 mmol/L
BE -1.9 mmol/L

Blood glucose level 108 mg/dl
SGOT 14 U/L
SGPT 8 U/L
HBsAg negative
Anti HCV negative
BT 800 minutes
CT 200 minutes
PT 10.9 second
APTT 27.3 second
Electrolytes:
Sodium 144 mmol/l
Potassium 4.1 mmol/l
Chloride 112 mmol/l
AP X-ray result:

Pneumothorax sinistra
Lung tumor suspected

Advice : Thorax CT scan
CT Scan Thorax result:

Pneumothorax sinistra with
lung colaps
Infected bronchiectasis dextra
Chronic active of duplex
tuberculosis
Spontaneous pneumothorax sinistra
Under nourish
Supporting therapy:
O
2
2 L/min via nasal canule
IVFD Dextrose 5% 30 gtt/min
Medicamentosa:
Ceftriaxon injection 2 x 1 g/iv
Ketorolac injection 2 x 10 mg/iv
Ranitidine injection 2 x 25 mg/iv
Usual diet:
Calorie 2000 gr
Protein 75 gr
Consult to surgical dept. for WSD procedure
Tuberculin test
Acid-fast Bacilli from sputum
Nov 14th
(2
nd
day)
Nov 15th
(3
rd
day)
Nov 16th
(4
th
day)
Nov 17th
(5
th
day)
Vital Sign RR : 50 x/m, PR : 140 RR: 36 x/min Normal Normal
Complaint Cough, Dyspneu
Cough, Dyspnea was
decreased
Cough with sputum (+),
Dyspnea (-)
Cough (-)
Physical
examination
Nasal flare (+), Subcostal
& Suprasternal retraction
(+), Asymmetrical chest
movement, hypersonor
in the right chest, BS
decrease on left chest
Nasal flare (+), Supra-
sternal retraction (+),
Asymmetrical chest
movement improving,
hypersonor in the right
chest, BS decreased on
left chest still audible
Appetite was improve,
Nasal flare (-), Supra-
sternal retraction
minimal, Asymmetrical
chest movement (-) Left
lung BS improving,
crackels on both lung
Symetric chest wall
movement, sonor on
right & left chest, WSD
(+), Crepitation (+),
ronchi +/+

Therapy
O
2
2 l/min, IVFD D
5%
,
Ceftriaxon 2x1g/iv,
Ketorolac 2x10mg/iv,
Ranitidine 2x25mg/iv,
stop oral intake
Planning: WSD
O
2
2 l/min, IVFD D
5%
,
Ceftriaxon 2x1g/iv,
Ketorolac 2x10mg/iv,
Ranitidine 2x25mg/iv,
Usual diet
1
st
day WSD attached
IVFD D
5%
,
Ceftriaxon 2x1g/iv,
Ketorolac 2x10mg/iv,
Ranitidine 2x25mg/iv,
ATD day 1, Usual diet
2
nd
day WSD attached
IVFD D
5%
,
Ceftriaxon 2x1g/iv,
Ketorolac 2x10mg/iv,
Ranitidine 2x25mg/iv,
ATD day 2, Usual diet
3
rd
day WSD attached
Laboratory Tuberculin test (done) CBC Thorax X-ray control Planning: Stop WSD
Laboratory
result
- -
Tuberculin test (+)
induration 30 mm
Chest X-ray control:
Pneumothorax
sinistra dissapear
Specific bilateral
pneumonia infection

Nov 18th
(6
th
day)
Nov 19th
(7
th
day)
Nov 20th
(8
th
day)
Nov 21th
(9
th
day)
Vital Sign Normal Normal Normal Normal
Complaint - - - -
Physical
examination
Active, retraction (-),
chest movement normal,
BS normal, crackles on
both lung
Active, retraction (-),
chest movement normal,
BS normal, crackles on
both lung
Active, retraction (-),
chest movement normal,
BS normal, crackles on
both lung
Active, retraction (-),
chest movement normal,
BS normal, crackles on
both lung
Therapy
IVFD D
5%
,
Ceftriaxon 2x1g/iv,
Ketorolac 2x10mg/iv,
Ranitidine 2x25mg/iv,
ATD day 3, Usual diet
IVFD D
5%
,
Ceftriaxon 2x1g/iv,
Ketorolac 2x10mg/iv,
Ranitidine 2x25mg/iv,
ATD day 4, Usual diet
IVFD D
5%
,
Ceftriaxon 2x1g/iv,
Ketorolac 2x10mg/iv,
Ranitidine 2x25mg/iv,
ATD day 5, Usual diet
IVFD D
5%
,
Ceftriaxon 2x1g/iv,
Ketorolac 2x10mg/iv,
Ranitidine 2x25mg/iv,
ATD day 6, Usual diet
Laboratory - - - -
Laboratory
result
- - - -
Nov 22th
(10
th
day)
Nov 23th
(11
th
day)
Nov 24th
(12
th
day)
Nov 25th
(13
th
day)
Vital Sign Normal Normal Normal Normal
Complaint
Her mother ask for
discharge from hospital
and continue oral
therapy at home
- - -
Physical
examination
Active, retraction (-),
chest movement normal,
BS normal, crackles on
both lung
- - -
Therapy
IVFD stop,
Stop intravenous drug
ATD day 7
Usual diet
- - -
Laboratory - - - -
Laboratory
result
- - - -
Left secondary spontaneous pneumothorax
Lung tuberculosis
Under nourish
Qua ad vitam : ad bonam
Qua ad sanationam : ad bonam
Pair of spongy, air-filled organs.
Located on either side of the chest
Trachea conduct inhaled air into the lungs through its bronchi
The bronchi than divide into smaller branches called bronchioles
Finally become microscopic air sac called alveoli
The lung covered by a thin tissue layer called pleura
The presence of air or gas
in the pleural cavity
(ie, the potential space
between the visceral and
parietal pleura of the lung),
which can impair
oxygenation and/or
ventilation.

It is every pneumothorax
that occurs suddenly.
This type of pneumothorax
can be classified into two
types; primary
pneumothorax and
secondary pneumothorax.
It is every pneumothorax
that occurs suddenly.
This type of pneumothorax
can be classified into two
types; primary
pneumothorax and
secondary pneumothorax.
It is one that occurs
without an apparent cause
and in the absence of
significant lung disease.
It is one that occurs in the
presence of existing
lung pathology
(i.e. Lung tuberculosis)
It is every pneumothorax
that resulted from trauma,
either blunt or penetreting
trauma, which cause
tearing of the pleura, chest
wall and lung. So that air
enters directly into the
pleural cavity.
PNEUMOTHORAX
SPONTANEOUS TRAUMATIC
Tension Pneumothorax Primary Non Iatrogenic
Secondary Iatrogenic
18 per 100,000 men / year
6 per 100,000 women / year

Secondary spontaneous
pneumothorax is a rare case
and its occurs at any age
(neonates, children, adult)
Sudden chest pain
Sudden shortness of breath
Respiratory failure
Sudden chest pain
Sudden shortness of breath
Respiratory failure
British Thoracic Society 2012
x
British Thoracic Society 2012
The clinical results are dependent on
the degree of collapse lung on the affected area

1. Amount of air in pleural cavity
2. Size of collapse lung
3. Tension Pneumothorax

Inspection asymmetricaly chest movement
Percussion hyper-resonance
Auscultation decrease breath sounds
Circulatory collapse due to Tension pneumothorax
Inspection asymmetricaly chest movement
Percussion hyper-resonance
Auscultation decrease breath sounds
Circulatory collapse due to Tension pneumothorax
British Thoracic Society 2012
x
10 cm
8 cm
6 cm
Amount of air in pleural cavity and
Size of collapse lung
% estimate size of pneumothorax
A + B + C (cm) x 10
3
Amount of air in pleural cavity
Size of collapse lung
> 2 cm
If lateral edge of lung is
>2cms from thoracic cage at
level of the hilum, then this
implies pneumothorax is at
least 50% (large).
Small pneumothorax is
equivalent to <30%.
Tension Pneumothorax Sign
A case of pneumothorax in a 14 year old
girl, was reported. Diagnosis was based
on history taking, physical and supporting
examinations. The management of this
patient is to remove the trap air with water
sealed drainage procedure. As mention
that the patient has a tuberculosis
infection, anti tuberculosis therapy was
prescribed. Intervention evaluated base
on improvement of the clinical symptoms.
The prognosis of the patient was good.
After 72 hours
Pair of spongy, air-filled organs
Thoracic cavity

This space is defined by:
Sternum anterior
Thoracic vertebrae posterior
Ribs lateral
Diaphragm inferior

Chest wall composed of
ribs, sternum, thoracic
vertebrae interlaced with
intercostal muscle

The diaphragm is the floor
of the thoracic cavity
Thoracic cavity
Right lung
Left lung
Mediastinum
Heart
Aorta and great
vessels
Esophagus
Trachea
Thymus
Breathing: inspiration
Brain signals the phrenic nerve
Phrenic nerve stimulates the
diaphragm (muscle) to contract
When diaphragm contracts, it
moves down, making the
thoracic cavity larger
(keep this in mind as we discuss physics)

Physics of gases
Air is made up of gas molecules
Gas molecules in a container collide and create a force
Pressure is the amount of the force created by the gas
molecules moving and colliding
When the volume of a container increases,
the pressure decreases
When the volume of a container decreases,
the pressure increases

If youre trying to squeeze as many people in a car as possible, they will
be under much higher pressure in a VW Beetle than the same number of
people would be in a bus.
Physics of gases: Boyles law
Physics of Gases
If two areas of different pressure communicate, gas will move
from the area of higher pressure to the area of lower pressure
This movement of air causes wind when a high pressure
system is near a low pressure system in the atmosphere

Physics of Gases
Another example
Inflated balloon = HIGH PRESSURE (POSITIVE)
Atmosphere = LOW PRESSURE (NEGATIVE)
Pop the balloon, and air rushes from an area of high
pressure inside the balloon to the low pressure in the
atmosphere
Breathing: inspiration
When the diaphragm contracts, it moves
down, increasing the volume of the thoracic
cavity. When the volume increases, the
pressure inside decreases.
Air moves from an area of higher pressure,
(the atmosphere), to an area of lower
pressure (the lungs).
Pressure within the lungs is called
intrapulmonary pressure.
Breathing: exhalation
Exhalation occurs when the phrenic
nerve stimulus stops
The diaphragm relaxes and moves up
in the chest
This reduces the volume of the
thoracic cavity
When volume decreases, intra-
pulmonary pressure increases.
Air flows out of the lungs to the
lower atmospheric pressure
Breathing
Remember, this is normally an unconscious process
Lungs naturally recoil, so exhalation restores the lungs to
their resting position
However, in respiratory distress, particularly with airway
obstruction, exhalation can create increased work of
breathing as the abdominal muscles try to force air out of
the lungs

Lungs are surrounded by thin tissue
called the pleura, a continuous
membrane that folds over itself.

Parietal pleura lines the chest wall
Visceral pleura covers the lung
(called the pulmonary pleura)

Pleural anatomy
Normally, two membranes are separated by the lubricating
pleural fluid. Fluid reduces friction, allowing the pleura to slide
easily during breathing.
Pleural anatomy
Ribs
Intercostal
muscles
Normal Pleural Fluid Quantity:
Approx. 25 ml per lung
Pleura
Parietal
Pleura
Visceral
Lung
Pleural physiology
The area between the pleura is called the pleural space
(sometimes referred to as potential space)
Normally, vacuum (negative pressure) in the pleural space keeps
the two pleura together & allows the lung to expand and contract.
During inspiration, the intrapleural pressure is approximately
-8cmH
2
0 (below atmosphere)
During exhalation, intrapleural pressure is approximately -4cmH
2
0


Pressures
Intrapulmonary pressure rises and falls with breathing
Equalizes to the atmospheric pressure at end-exhalation
(defined as 0 cmH
2
O because other pressures are compared
to it as a baseline)
Intrapleural pressure also fluctuates with breathing ~4
cmH
2
O less than the intrapulmonary pressure
The pressure difference of 4 cmH
2
O across the alveolar wall
creates the force that keeps the stretched lungs adherent to
the chest wall
When pressures are disrupted
If air or fluid enters the pleural
space between two pleura, the
-4cmH
2
0 pressure gradient
that normally keeps the lung
against the chest wall
disappears & the lung collapse.
Intrapulmonary pressure: -4cmH
2
0

Intrapleural pressure: -8cmH
2
0
Conditions requiring chest drainage
Air between the pleura is a pneumothorax
Parietal pleura
Visceral pleura Pleural space
Conditions requiring chest drainage
Blood in the pleural space is a hemothorax
Conditions requiring chest drainage
Transudate or exudate in the pleural space is a pleural effusion

Conditions requiring chest drainage: tension pneumothorax
Tension pneumothorax occurs
when a closed pneumothorax
creates positive pressure in the
pleural space that continues to
build
That pressure is then
transmitted to the mediastinum
(heart and great vessels)
Conditions requiring chest drainage: mediastinal shift
Mediastinal shift occurs when
the pressure gets so high that it
pushes the heart and great
vessels into the unaffected side
These structures are
compressed from external
pressure and cannot expand to
accept blood flow

Mediastinal shift
Conditions requiring chest drainage: mediastinal
shift
Mediastinal shift can quickly lead to cardiovascular collapse
The vena cava and the right side of the heart cannot accept
venous return
With no venous return, there is no cardiac output
No cardiac output = not able to sustain life !!