RESPIRATORY DISTRESS

SYNDROME

Supervisor : dr. H. Emil Azlin, M. Ked (Ped), Sp.A (K)

Presented by : Dara Novea Hutagalung
Thamarai Somu
Hade Praja Hutasoit

Introduction
Neonatal respiratory distress syndrome (RDS) is a
condition of pulmonary insufficiency that in its
natural course commences at or shortly after birth
and increases in severity over the first 2 days of life.
Clinically, RDS presents with early respiratory
distress comprising cyanosis, grunting, retractions
and tachypnea.
RDS is due to a deficiency of alveolar surfactant
along with structural immaturity of the lung and it
is mainly, but not exclusively, a disease of preterm
babies.
The management of these infants is complex and
requires a multidisciplinary team approach to obtain
best outcomes.

Definition
Neonatal respiratory distress syndrome
(RDS) or hyalin membran disease is a
condition of pulmonary insufficiency that in
its natural course commences at or shortly
after birth and increases in severity over the
first 2 days of life.
Clinically,
RDS
presents
with
early
respiratory distress comprising cyanosis,
grunting, retractions and tachypnea.

Epidemiology
About 12 percent of babies born in the United States
are preterm, which is higher than in other developed
countries.
In 2005, there were 4,138,000 live births in the United
States, and a slightly larger number of babies were
affected with RDS because the rate of premature
births had increased from 11.6 percent to 12.7
percent, mainly due to a rise in late preterm births.
In Indonesia, out of 950,000 baby with less weight who
where born every year, approximately 150,000 baby
suffered from respiratory distress.

Patophysiology
Prematurity
Surfactant Deficiency
Atelactasis
Hipoxemia & Hipercarbia
Respiratory & Metabolic Acidosis
Pulmonary Vasoconstriction
Impaired endothelial and
epithelial integrity
Proteinaceous exudate

RDS

Clinical Manifestation

Cyanosis
Tachypnea
Shortness of breath and grunting sounds while breathing
Retraction
apnea
Nasal flaring
Decreased urine output
Puffy or swollen arms and legs
Rapid breathing/Shallow breathing
Increased oxygen requirement
Paradoxical chest wall movement with breathing
Accessory muscle usage
Chest x-ray showing atelectasis, air bronchograms, and
granular infiltrates

DIAGNOSIS
RDS diagnosis can be enforced through
clinical manisfestation, chest x-ray and can
be confirmed with gas blood analysis.
Severity level of respiratory distress can be
evaluated through Silverman-Anderson score
or Downes score.

Management
The goals of management of an infant
with RDS are to :
Avoid hypoxemia and acidosis
Optimize fluid management which is
avoid fluid overload and resultant body
and pulmonary edema while averting
hypovolemia and hypotension
Reduce metabolic demands and
maximize nutrition
Minimize lung injury secondary due to
volutrauma and oxygen toxicity

The three most important advances in

prevention and treatment of RDS have
been:
antenatal glucocorticoids
continuous positive airway pressure
(CPAP) and positive end-expiratory
pressure (PEEP)
surfactant replacement therapy. These
have dramatically decreased morbidity
and mortality from RDS.

Case Report
Baby PR, a 11 days old girl, with 1.49kg of
body weight and 41 cm of body height,
consulted to perinatology in RSUP Haji Adam
Malik Medan as soon as she was born on 18th
July at 11:36 AM. Her main complaint was
difficulty in breathing.

 History of disease :
Baby PR, a girl, 11 days old, with 1.49 kg of BW
and 41 cm of BH, consulted to perinatalogy in RSUP
Haji Adam Malik Medan on 18th July at 11:36 AM
with difficulty in breathing as a chief complaint. It
has been experienced by patient two hours after she
was born in HAM hospital. The patient was born by
sectio cesarean and doesnt cry immediately after
birth. History of milk feeding which is incontinuous
when milk feeding. History of turning blue found two
hours after born according to doctor, blue has been
found in lips, arm and shoulder. Theres no fever,
vomiting or diarrhea found.

History of medication
: None
History of family
: None
History of parents medication : None
History of pregnancy
: The age of the
patients
mother was 41 during
pregnancy. The gestation
age was
28 weeks.
History of birth
: Birth was assisted by
doctor
in HAM hospital. The patient
was born sectio cesarean and
doesnt cry immediately after
birth.
Body weight at birth
was 1490 gram,
body length at
birth was 41cm and head
circumference was 28cm.
Cyanosis (+), Jaundice (-).
History of feeding
: Breast feeding (-)

Physical Examination:
Present status:
Sensorium: compos mentis
Body temperature: 37.2C
HR: 142 bpm
RR: 56 bpm
BW: 14.9 kg
BL: 41 cm
Chest circumference (CC): 26cm
Head circumference (HC): 28
cm
Downes score: 4
anemic (-), icteric (-), dyspnea (+), cyanosis (+), edema (-).

Localized status:
Head :
Head
: frontal within normal limit
Face : edema (-), icteric (-)
Eye : light reflex (+/+), isochoric pupil, palpebral
conjunctiva pale (-/-), icteric (-)
Ears : both ear lobe in normal morphologic
Nose : septum deviation (-), nasal CPAP (-), NGT (-)
Mouth : normal
Neck : Lymph node enlargement (-), neck stiffness (-)

 Thorax
:
Symmetrical
fusiform,
retraction
(+)
epigastrial,
Intercostalis, suprasternal,
icteric (-).

HR: 134 bpm, regular, murmur (-/-)

RR: 38 bpm, regular, ronchi (-/-)
Abdomen :
Soepel, normal peristaltic, liver and spleen
unpalpable, icteric (-)
Extremities :
adequate p/v, felt warm, CRT < 3, pitting
oedema (-/-), icteric (-)
Anogenital : Female

 Differential diagnosis :
1) Respiratory distress
2) Transient tachypnea of the newborn
3) Meconium aspiration syndrome
Working diagnosis
:
1) Respiratory Distress ec DD/ - Hyalin
Membrane Disease
2) Apnoe of Prematurity
3) Suspect of sepsis
4) Baby born with less weight

Laboratory Finding :
Complete Blood Analysis (July 18th 2016 / 15:54)
Test

Result

Unit

References

Hemoglobin

11.0

g/dL

17-22

Erythrocyte

3.05

106/L

4.50-6.50

Leucocyte

13.440

103/L

10.000-30.000

Thrombocyte

144000

103/L

150000-350000

Hematocrite

34

31-59

Eosinophil

0.70

1.00-3.00

Basophil

0.60

0.00-1.00

Neutrophil

57.00

50.00-70.00

Lymphocyte

27.80

20.00-40.00

Monocyte

13.90

2.00-8.00

Neutrophil absolute

7.65

103/L

5.5-18.3

Lymphocyte absolute

3.74

103/L

2.8-9.3

Monocyte absolute

1.87

103/L

0.5-1.7

Eosinophil absolute

0.10

103/L

0.02-0.70

Basophil absolute

0.08

103/L

0.1-0.2

MCV

111

fL

80-97

MCH

36.1

pg

26.5-33.5

MCHC

32.4

g/dL

31.5-36.0

Clinical Chemistry :
Blood Gas Analysis

Test

Result

Unit

References

pH

7.270

7.35-7.45

pCO2

27.0

mmHg

38-42

pO2

172.0

mmHg

85-100

HCO3

12.4

mmol/L

22-26

Total CO2

13.2

mmol/L

19-25

BE

-13.0

mmol/L

(-2) - (+2)

Saturasi O2

99.0

95-100

Electrolyte
Natrium (Na)

134

mEq/L

135-155

Potassium(K)

5.6

mEq/L

3.6-5.5

Chloride (Cl)

107

mEq/L

96106

Kalsium (Ca)

7.90

mEq/L

8.410.2

Test Lain :

Procalcitonin

16.20 ng/mL

< 0.05

Therapy
Recommended: Infant Radiant Warmer Theraphy
with target skin temperature 36,5-37,5.
Nasal CPAP with PEEP: 5-6 cmH2O, Flow 8 liter
per minute, FiO2: 35% Target of oxygen
saturation: 92-96%.
Total fluid requirement: 80 cc/kgBW/day = 120cc/
day
Parenteral 80cc/kgBW/day = 120cc/day
IVFD Dex 10% 5cc/hour
Ceftazidime injection 75mg/12 hour/iv (Day 1)
Gentamicin injection 8mg/36 hour/iv (Day 1)
Vitamin K Injection 0.5mg/IM
Gentamicin eye drops 1gtt (ED)

Follow Up

July 19th 2016

S

Difficulity in breathing (+); icteric (-); fever (-); inactive movement; sucking refleks seen
weak

Sens: CM; temperature: 37.0o C BW: 1.49 kg, BH: 41 cm

Head :
Head
Eye

: Frontal within normal limit.

: light reflex (+/+); isochoric pupil (+/+), pale conjungtiva palpebral inferior (-/-)

Face
Ear

: icteric (-)
: both ear lobe in normal morphologic

Nose

: within normal range, O2 via nasal CPAP (+), NGT (-)

Mouth : using NGT (-), dysphagia (-)

Neck

: lymph node enlargement (-), neck stiffness (-)

Thorax : symmetric fusiform, retraction (+), icteric (-)

HR : 145 bpm, reguler, murmur(-)
RR : 50 bpm, reguler, rhonchi (-)
Abdomen : peristaltic (+) normal, hepar/ lien, icteric (-)
Extremities : pulse : 145 bpm, regular, adequate p/v, warm, CRT < 3,
BP : 100/50 mmHg, muscular rigidity (+)
Systemic Infection: stable, fever (-), temperature: 37.0
18/7 : Leu: 13.440 10/L
Systemic Hematologic: stable, pale and bleeding not found
18/7: Hb/Ht/Tr: 11/34/144.000
Systemic musculoskeletal: Still not stable. extremital cyanosis (+), from left arm to left shoulder
Systemic urogenital: Stable, enough urine output

1. Respiratory distress ec DD/ - Hyaline Membrane Disease

2. Apnoe of Prematurity
3. Suspect of sepsis
4. Baby born with less weight

Infant Radiant Warmer Theraphy with target skin temperature 36,537,5.

Nasal CPAP with FiO2: 30%, PEEP: 4-5, Flow: 8 liter per minute.
Oxygen saturation: 94-95%.
Total fluid requirement: 80 cc/kgBW/day = 120cc/ day
Parenteral 80cc/kgBW/day = 120cc/day
IVFD D 12,5% + Ca Gluconas 10cc 4cc/hour
Aminosteril 6%

2,0gr/kgBW/day = 2,58 gr/day = 49,6cc/day =

2,0cc/hour/iv
Ivelip 20% 0.5gr/kgBW/day = 1,24 gr/day = 6.2cc/day = 0,2cc/hour/iv
Enteral: Tropic Feeding 20cc/kgBW/day = 29.8cc/day = 2,5cc/2hour
Ceftazidime injection 75mg/12 hour/iv (Day 2)
Gentamicin injection 8mg/36 hour/iv (Day 2)
Heparin Injection 0.3cc/hour

July 20th 25th 2016

S

Difficulity in breathing (+) become lesser; icteric (-); fever (-); inactive
movement; sucking refleks seen weak; vomiting (+),4x

Sens: CM; temperature: 36.4o C BW: 1.49 kg, BH: 41 cm

Head :
Head
Eye

: Frontal within normal limit.

: light reflex (+/+); isochoric pupil (+/+), pale conjungtiva
palpebral inferior (-/-)

Face
Ear
Nose

: icteric (-)
: both ear lobe in normal morphologic
: within normal range, O2 via nasal CPAP (+), NGT (-)

Mouth : using NGT (-), dysphagia (-)

Neck

: limph node enlargement (-), neck stiffness (-)

Thorax : symmetric fusiform, retraction (+), icteric (+)

HR : 140 bpm, reguler, murmur(-)
RR : 48 bpm, reguler, rhonchi (-)
Abdomen : peristaltic (+) normal, hepar/ lien, icteric (-)
Extremities : icteric (-), adequate p/v, warm, CRT < 3,

System Metabolic: stable, Abdomen: distension (-)

18/7 : pH:7.270/ pCO2:27/ pO2:172/ HCO3:12.4/ Total CO2:13.2/
BE:-23/ Sat O2:99%
System Infection: stable, fever (-), temperature: 36.9
18/7 : Leu: 13.440 10/L, Procalcitonin:16.2
System Hematologic: stable, pale and bleeding not found
18/7: Hb/Ht/Tr: 11/34/144.000
System musculoskeletal: Still not stable, extremital cyanosis (+), from
left arm to left shoulder
System urogenital: Stable, enough urine output

1. Respiratory distress ec Hyaline Membrane Disease

2. Apnoe of Prematurity
3. Suspect of sepsis

4. Baby born with less weight

Infant Radiant Warmer Theraphy with target skin temperature 36,537,5.
Nasal CPAP with FiO2: 30% , PEEP: 4-5, Flow: 8 liter per minute.
Oxygen saturation: 94-95%.
Total fluid requirement: 100 cc/kgBW/day = 210cc/ day
Parenteral 100cc/kgBW/day = 149cc/day
IVFD D12,5% + Ca Gluconas 10cc
Aminosteril

6%

2gr/kgBW/day

91,9cc/day
=

12.98

5cc/hour

gr/day

49,7cc/day

2,0cc/hour/iv
Ivelip 20% 1gr/kgBW/day = 1,49 gr/day = 7.4cc/day = 0,3cc/hour/iv
Enteral: fasting
Ceftazidime injection 75mg/12 hour/iv (Day 3-8)
Gentamicin injection 8mg/36 hour/iv (Day 3-8)
Heparin Injection 0.3cc/hour
Recommended: - Light therapy 1x24 hour

July 26 - 28th 2016

S

Difficulity in breathing (+) become lesser; inactive movement

Sens: CM; temperature: 36.9o C BW: 1.49 kg, BH: 41 cm

Head :
Head

: Frontal within normal limit.

Eye

: light reflex (+/+); isochoric pupil (+/+), pale conjungtiva

palpebral inferior (-/-)

Face
Ear
Nose

: icteric (-)
: both ear lobe in normal morphologic
: within normal range, O2 via nasal CPAP (+), NGT (-)

Mouth : using OGT (+), dysphagia (-)

Neck

: lymph node enlargement (-), neck stiffness (-)

Thorax : symmetric fusiform, retraction (+), icteric (-)

HR : 140 bpm, reguler, murmur(-)
RR : 43 bpm, reguler, rhonchi (-)
Abdomen : peristaltic (+) normal, hepar/ lien, icteric (-)
Extremities :icteric (-) adequate p/v, warm, CRT < 3,

System Metabolic: stable, icteric (-)

25/7: kolesterol total : 123
Trigliserida : 105
Ca/Na/K : 8.2/137/4.7

GDS : 59

HDL/LDL : 34 / 79
P:3.3/ Cl:109/Mg:1.95

Ca ion:1.2
System Infection: still not stable, fever (-), temperature: 36.9
25/7 : Leu: 14.490 10/L
25/7: Procalcitonin:0.45
System Hematologic: stable, pale and bleeding not found
25/7: Hb/Ht/Tr: 9.1/28/490.000
CRP: <0.7
System musculoskeletal: Still not stable, extremital cyanosis (+) from
left arm to left shoulder
System urogenital: Stable, enough urine output

1. Respiratory distress ec Hyaline Membrane Disease

2. Apnoe of Prematurity
3. Suspect of sepsis
4. Baby born with less weight

Infant Radiant Warmer Theraphy with target skin temperature 36,537,5.

Nasal CPAP with 1/2 liter per minute.
Total fluid requirement: 150 cc/kgBW/day
Parenteral 50cc/kgBW/day
IVFD D5% NaCl 0,225% (430cc) + D40% (70cc) + KCl 10 mEq + Ca
Gluconas 10cc

2cc/hour

Aminosteril 6% 3gr/kgBW/day = 4.97 gr/day = 3cc/hour

Ivelip 20%

3gr/kgBB/day

2.98gr/day

9.6cc/hour

Enteral: 100cc/kgBW/day = 149cc/day

Breast feeding diet/substitute of breastfeeding: 12cc/2jam/orogastric
tube
Ceftazidime injection 75mg/12 hour/iv (Day 9-11)
Gentamicin injection 8mg/36 hour/iv (Day 9-11)
Heparin Injection 0.3cc/jam (Day 9-11)

July 29th - August 1st 2016

S

Cry out loud; active movement; sucking refleks seen weak

Sens: CM; temperature: 36.8o C BW: 1.45 kg, BH: 44 cm

Head :
Head
Eye

: Frontal within normal limit.

: light reflex (+/+); isochoric pupil (+/+), pale conjungtiva
palpebral inferior (-/-)

Face
Ear
Nose

: normal
: both ear lobe in normal morphologic
: within normal range, O2 via nasal CPAP (-), NGT (-)

Mouth : using OGT (+), dysphagia (-)

Neck

: limph node enlargement (-), neck stiffness (-)

Thorax : symmetric fusiform, retraction (-), icteric (-)

HR : 142 bpm, reguler, murmur(-)
RR : 46 bpm, reguler, rhonchi (-)
Abdomen : peristaltic (+) normal, hepar/ lien, icteric (-)
Extremities : HR:142bpm, icteric (-) adequate p/v, warm, CRT < 3,

1. Respiratory distress ec Hyaline Membrane Disease

2. Apnoe of Prematurity
3. Suspect of sepsis
4. Baby born with less weight

Infant Radiant Warmer Theraphy with target skin temperature 29,233,2.

Total fluid requirement: 150 cc/kgBW/day
Parenteral 40cc/kgBW/day = 58cc/day
IVFD D5% NaCl 0,225% (430cc) + D40% (70cc) + KCl 10 mEq + Ca
Gluconas 10cc

3cc/hour

Enteral: 110cc/kgBW/day = 162cc/day

Breast

feeding

diet/substitute

of

breast

14cc/2jam/orogastric tube
Ceftazidime injection 75mg/12 hour/iv (Day 12-15)
Gentamicin injection 5mg/24 hour/iv (Day 12-15)

feeding:

August 2nd 2016

S

Cry out loud; active movement; sucking refleks seen weak

Sens: CM; temperature: 36.6o C BW: 1.47 kg, BH: 44 cm

Head :
Head
Eye

: Frontal within normal limit.

: light reflex (+/+); isochoric pupil (+/+), pale conjungtiva
palpebral inferior (-/-)

Face
Ear
Nose

: Normal
: both ear lobe in normal morphologic
: within normal range, O2 via nasal CPAP (-), NGT (-)

Mouth : using OGT (+), dysphagia (-)

Neck

: limph node enlargement (-), neck stiffness (-)

Thorax : symmetric fusiform, retraction (-), icteric (-)

HR : 132 bpm, reguler, murmur(-)
RR : 48 bpm, reguler, rhonchi (-)
Abdomen : peristaltic (+) normal, hepar/ lien, icteric (-)
Extremities :icteric (-) adequate p/v, warm, CRT < 3,

1. Respiratory distress ec Hyaline Membrane Disease

2. Apnoe of Prematurity
3. Suspect of sepsis
4. Baby born with less weight

Infant Radiant Warmer Theraphy with target skin temperature 29,233,2.

Total fluid requirement: 160 cc/kgBW/day = 235cc/ day
Parenteral threeway
Enteral: 160cc/kgBW/day
Breast feeding diet/substitute of breastfeeding: 19cc/2jam/orogastric
tube
Aminofilin injection 4mg/12 hour/iv (Day 16)
Ferris drop 1 x 0.3cc
Zamel drop 1 x 0.3cc
Nyastatin drop 4x0,5cc
Recommended : vitamin E 100 IU 1 x 0.25cc

August 3rd 2016

S

Cry out loud; active movement; sucking refleks seen weak

Sens: CM; temperature: 36.6o C BW: 1.48 kg, BH: 44 cm

Head :
Head
Eye

: Frontal within normal limit.

: light reflex (+/+); isochoric pupil (+/+), pale conjungtiva
palpebral inferior (-/-)

Face
Ear
Nose

: Normal
: both ear lobe in normal morphologic
: within normal range, O2 via nasal CPAP (-), NGT (-)

Mouth : using OGT (+), dysphagia (-)

Neck

: limph node enlargement (-), neck stiffness (-)

Thorax : symmetric fusiform, retraction (-), icteric (-)

HR : 152 bpm, reguler, murmur(-)
RR : 44 bpm, reguler, rhonchi (-)
Abdomen : peristaltic (+) normal, hepar/ lien, icteric (-)
Extremities :icteric (-) adequate p/v, warm, CRT < 3,

1. Respiratory distress ec Hyaline Membrane Disease

2. Apnoe of Prematurity
3. Unproven sepsis
4. Baby born with less weight

Infant Radiant Warmer Theraphy with target skin temperature 29,233,2.

Total fluid requirement: 160 cc/kgBW/day = 234cc/ day
Parenteral : threeway
Enteral: 160cc/kgBW/day
Breast feeding diet/substitute of breastfeeding: 20cc/2jam/orogastric
tube
Aminofilin injection 4mg/12 hour/iv (Day 17)
Ferris drop 1 x 0.3cc
Zamel drop 1 x 0.3cc
Nyastatin drop 4x0,5cc
Vitamin E 100 IU 1 x 0.3cc

August 4th 2016

S

Cry out loud; active movement; sucking refleks seen good; fever (-)

Sens: CM; temperature: 36.6o C BW: 1.48 kg, BH: 44 cm

Head :
Head
Eye

: Frontal within normal limit.

: light reflex (+/+); isochoric pupil (+/+), pale conjungtiva
palpebral inferior (-/-)

Face
Ear
Nose

: Normal
: both ear lobe in normal morphologic
: within normal range, O2 via nasal CPAP (-), NGT (-)

Mouth : using OGT (+), dysphagia (-)

Neck

: limph node enlargement (-), neck stiffness (-)

Thorax : symmetric fusiform, retraction (-), icteric (-)

HR : 140 bpm, reguler, murmur(-)
RR : 48 bpm, reguler, rhonchi (-)
Abdomen : peristaltic (+) normal, hepar/ lien, icteric (-)
Extremities :icteric (-) adequate p/v, warm, CRT < 3,

1. Respiratory distress ec Hyaline Membrane Disease

2. Apnoe of Prematurity
3. Unproven sepsis
4. Baby born with less weight

Infant Radiant Warmer Theraphy with target skin temperature 29,233,2.

Total fluid requirement: 160 cc/kgBW/day = 240cc/ day
Parenteral : Enteral: 160cc/kgBW/day
Breast feeding diet/substitute of breastfeeding: 20cc/2jam/orogastric
tube
Aminofilin injection 4mg/12 hour/iv (Day 18)
Ferris drop 1 x 0.3cc
Zamel drop 1 x 0.3cc
Nyastatin drop 4x0,5cc
Vitamin E 100 IU 1 x 0.3cc

August 5th 13th 2016

S

Cry out loud; active movement; sucking refleks seen weak; fever (-)

Sens: CM; temperature: 37.9o C BW: 1.48 kg, BH: 44 cm

Head :
Head
Eye

: Frontal within normal limit.

: light reflex (+/+); isochoric pupil (+/+), pale conjungtiva

palpebral inferior (-/-)

Face
Ear
Nose

: Normal
: both ear lobe in normal morphologic
: within normal range, O2 via nasal CPAP (-), NGT (-)

Mouth : using OGT (+), dysphagia (-)

Neck

: limph node enlargement (-), neck stiffness (-)

Thorax : symmetric fusiform, retraction (-), icteric (-)

HR : 140 bpm, reguler, murmur(-)
RR : 48 bpm, reguler, rhonchi (-)
Abdomen : peristaltic (+) normal, hepar/ lien, icteric (-)
Extremities :icteric (-) adequate p/v, warm, CRT < 3,

1. Respiratory distress ec Hyaline Membrane Disease

2. Apnoe of Prematurity
3. Unproven sepsis
4. Baby born with less weight

Infant

Radiant

Warmer

Theraphy

with

target

skin

temperature 36,5-37,5.
Total fluid requirement: 160 cc/kgBW/day
Parenteral : Enteral: 160cc/kgBW/day
Breast

feeding

diet/substitute

of

23cc/2jam/orogastric tube
Ferris drop 1 x 0.3cc
Zamel drop 1 x 0.3cc
Nyastatin drop 4x0,5cc
Vitamin E 100 IU 1 x 0.3cc
Recommended : Observe temperature
Vitamin K injection 1g/ IM per week

breastfeeding:

August 14 - 17th 2016

S

Cry out loud; active movement; sucking refleks seen weak; fever (-)

Sens: CM; temperature: 36.6o C BW: 1.53 kg, BH: 44 cm

Head :
Head
Eye

: Frontal within normal limit.

: light reflex (+/+); isochoric pupil (+/+), pale conjungtiva
palpebral inferior (-/-)

Face
Ear
Nose

: Normal
: both ear lobe in normal morphologic
: within normal range, O2 via nasal CPAP (-), NGT (-)

Mouth : using OGT (+), dysphagia (-)

Neck

: limph node enlargement (-), neck stiffness (-)

Thorax : symmetric fusiform, retraction (-), icteric (-)

HR : 148 bpm, reguler, murmur(-)
RR : 50 bpm, reguler, rhonchi (-)
Abdomen : peristaltic (+) normal, hepar/ lien, icteric (-)
Extremities :icteric (-) adequate p/v, warm, CRT < 3,

1. Respiratory distress ec Hyaline Membrane Disease

2. Apnoe of Prematurity
3. Unproven sepsis
4. Baby born with less weight

Infant

Radiant

Warmer

Theraphy

with

target

skin

temperature 36,5-37,5.
Total fluid requirement: 160 cc/kgBW/day
Parenteral : Enteral: 160cc/kgBW/day
Breast

feeding

diet/substitute

23cc/2jam/orogastric tube
Ferris drop 1 x 0.3cc
Zamel drop 1 x 0.3cc
Nyastatin drop 4x0,5cc
Vitamin E 100 IU 1 x 0.3cc
Recommeded : tranfuse PRC III 11 cc

of

breastfeeding:

August 18 - 26th 2016

S

Cry out loud; active movement; sucking refleks seen good; fever (-)

Sens: CM; temperature: 37.0o C BW: 1.91 kg, BH: 44 cm

Head :
Head

: Frontal within normal limit.

Eye

: light reflex (+/+); isochoric pupil (+/+), pale conjungtiva

palpebral inferior (-/-)

Face
Ear
Nose

: Normal
: both ear lobe in normal morphologic
: within normal range, O2 via nasal CPAP (-), NGT (-),
Left anterior nasal cavum closed.

Mouth : using OGT (+), dysphagia (-)

Neck

: limph node enlargement (-), neck stiffness (-)

Thorax : symmetric fusiform, retraction (-), icteric (-)

HR : 142 bpm, reguler, murmur(-)
RR : 48 bpm, reguler, rhonchi (-)
Abdomen : peristaltic (+) normal, hepar/ lien, icteric (-)
Extremities :icteric (-) adequate p/v, warm, CRT < 3,

1. Respiratory distress ec Hyaline Membrane Disease

2. Apnoe of Prematurity
3. Unproven sepsis
4. Baby born with less weight
5. Sinekia cavum sinistra dextra

Infant

Radiant

Warmer

Theraphy

with

target

skin

temperature 36,5-37,5.
Total fluid requirement: 200 cc/kgBW/day
Parenteral : Enteral: 200cc/kgBW/day
Breast

feeding

diet/substitute

30cc/2jam/oral
Ferris drop 1 x 0.3cc
Zamel drop 1 x 0.3cc
Nyastatin drop 4x0,5cc
Vitamin E 100 IU 1 x 0.3cc
Recommended : tranfuse PRC III 11 cc

of

breastfeeding:

Discussion
Theory
Definition
Neonatal

Case
Baby PR is a preterm baby with
respiratory

distress gestational age 32 - 34 weeks who

syndrome (RDS) is a condition of suffered

with

main

complain

pulmonary insufficiency that in its difficulty in breathing. It has been

natural

course

commences

at

or experienced by patient two hours

shortly after birth and increases in after she was born in HAM hospital.
severity over the first 2 days of life.
Clinically, RDS presents with early
respiratory

distress

comprising

cyanosis, grunting, retractions and

tachypnea.
deficiency

RDS
of

is

alveolar

due

to

surfactant

along with structural immaturity of

the lung and it is mainly, but not
exclusively,
babies.

a disease of preterm

However,

defining

RDS

is

Theory
Clinical Manifestation

Case
Baby PR suffered from chief complaint

Signs of RDS appear immediately after

difficulty in breathing.

birth or within 4 h. RDS is characterized History

by

tachypnea

intercostal

(>60

and

breaths/min),

subcostal

retractions,

nasal flaring, grunting, and cyanosis in

room air. Tachypnea is due to an attempt
to

increase

minute

ventilation

to

compensate for a decreased tidal volume

of

milk

feeding

which

is

incontinous when milk feeding.

History of turning blue found two
hours after born according to doctor,
blue has been found in lips, arm and
shoulder.

and increased dead space. Retractions Theres no fever, vomiting or diarrhea

found.
occur as the infant is forced to generate a
high intrathoracic pressure to expand the Through physical examination found
poorly compliant lungs. Grunting results

retraction

from the partial closure of the glottis

intercostal.

during forced expiration in an effort to

maintain

FRC.

improvement

with

After

an

initial

resuscitation

and

stabilization, an uncomplicated course is

often

characterized

worsening

for

48

by
to

72

progressive
h.

Recovery

in

epigastrial

and

Theory

Case

Diagnosis

Clinical criteria: - Cyanosis

Based

- Apnea

fulfilled some of the clinical and laboratory

- Decreased urine output

criteria

- Nasal flaring

distress:

- Puffy or swollen arms and legs

a) Cinical manifestation

- Rapid breathing

- Patient suffers from difficulty in breathing

- Shallow breathing
- Shortness of breath and grunting

as

also

respiratory

after born according to doctor, blue has

been found in lips, arm n shoulder.

- Poor lung aeration

infiltrates

diagnosed

patient

- History of turning blue found two hours

- Breath sounds that include rales

bronchograms, and granular

this

hours after she was born in HAM hospital.

with breathing

- Chest x-ray showing atelectasis, air

be

theory,

It has been experienced by patient two

- Paradoxical chest wall movement

- Accessory muscle usage

to

the

known as apnea.

sounds while breathing

- Increased oxygen requirement

on

Theory

Case

Theraphy

Theraphy that used in this case is:

Theraphy which is given for RDS is:

-Respiratory

management

- Nasal CPAP with PEEP: 4-5 cmH2O,

through Flow 8-10 liter per minute, FiO2: 30%

CPAP

Target of oxygen saturation: 94-95%.

- Antibiotic theraphy such as ampicilin - Gentamicin injection 8mg/36 hour/iv

and gentamicin.

- Infant Radiant Warmer Theraphy with

- Thermoregulation such as radiant target skin temperature 36,5-37,5.

warmer.

Thank You