management for rds

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PREMATURITY



Case presentation 1



Baby of madam M, delivered via SVD at 35week and 6 days of

POA, was admitted into NICU due to difficulty in breathing which

developed immediately after he was delivered.



Madam M

± 31 years old nurse, married

± Gravida 2 Para 1

± POA:35 weeks and 6days

± LMNP: 26/2/10

± EDD: 3/12/10

± Was admitted through OGAC

± Due to preterm labour?



Planned and wanted pregnancy

Noted pregnant at 6/52 POA

8/52 POA: UPT done in panel clinic, antenatal booking, first

U/S done, blood tests done

± Blood group: B positive

± VDRL/TPHA/HIV: negative

± Hep B: negative

± She was told that the baby growth was corresponding tothe date



Complicated antenatal:

± GDM on d/c

MGTT @ 20wk: 8.0/ 9.0mmol/L

± Gestational hypertension

diagnosed at 33weeks POA

Admitted 2 times for BP stabilization

on labetalol 40mg tds

± H/O PE at 2002- SVD at 34/52 (1st pregnancy)

± H/O subfertility for 3 years



At 35/52+ 6/7 of POA:

± Contraction pain : increased frequency and duration

± No signs and symptoms of PE : blurring of vision, headache, nausea, vomit, epigastric discomfort or seizure

± BP : 190/110mmHg PR: 68mmHg

± P/E abdomen: singleton, longitudinal lining with cephalicpresentation, head not engaged (5/5), fetal heart ratedetected by daptone, smaller than date (32/52) ?

± Proteinuria 1+

± CTG: appropriate for its gestation age

± u/s: growth up to date?

± Diagnosis: severe PE and was admitted to HDU



Past medical history:

± No hypertension, DM, hepB carrier , heart disease

No known allergy to any drug or food.

Past obstetric history:

± 2002SVD with severe PE at 34/52, baby boy, 1.8kg, well

currently

Family history: mother DM. No family history of hypertension.

Social: married for 9 years, worked as a nurse in ppukm, husband worked as technician. No smoking, no consume

alcohol.



In HDU:



Labour :

± Spontaneous onset

± ARM

± No maternal pyrexia

± Amniotic fluid: normal, non-foul smelling

± Medication: antihpt, steroids, tocolytic, pethidine, epidural, others??

First stage: ± Duration:

± Vertex presentation

± No fetal distress

± CTG(external): normal

± No meconium stained liquor

Second stage:

± Duration:

± SVD, uncomplicated

± Normal placental, weight 580g



Baby¶s particular :

± baby boy

± 1650hours (25/12/10)

± Birth weight : 2.82kg, borderline premature at 35/52+ 6/7 ± APGAR : 8/9

± Clear liquor at delivery, no instrument used for delivery.



± reason for referral: grunting at 1.5 hour of life

mother

± gestational hypertension on 33/52 on T.labetalol 40mg tds

admitted 2x for BP stabilization. BP 190/110 at PAC

± Gdm on diet control

± Subfertility 3 years- spontaneous conception

± h/o severe PE 8 years ago

Baby

- 35W+6D informed by S/N patient grunting at 1hr 20min of

life.



Progress and management of baby

- Attended stat, patient was put under head box 8L/min.

however persistently grunting

- SpO2 88%-92% , temp: 36.8C

- Silverman score: 2-3/10

- Patient was then put under nasal CPAP PEEP 5cmH20, FiO2

40%

- Saturation maintained >95%

- Dxt: 2.8mmol/L. not jittery. Given bolus 6cc D10%, then started

on IVD maintainence 7cc/hr D10% (TF 60cc/kg/day)- CBG- mild respiratory acidosis



re-examined:

± active, pink, good cry

± Vital signs:

± Silverman score: 1-2/10 on nasal CPAP ± PE: no abnormality detected.( facies, scalp, suture, fontanelle,

ears, eyes, neck, nose, mouth, respiratory system, cvs system,

abdominal, umbilicus, anus, spine, arms, hands, legs, hips,

genitalia, tone, reflexes including grasp, moro and sucking)



Problem:

± Borderline premature at 35w+6d

1) respiratory distress secondary to hypoglycemia

2) Respiratory distress syndrome secondary to infant of diabetic mother

Differential: congenital pneumonia



25/12, 8.35pm

± Review patient at 45 min on NCPAP

± Noted persistently grunting with mild SCR

± Spo2 fluctuating 85%-95% under FiO2 70% NCPAP PEEP 5cmH2O

± Post bolus 30min: dxt 12.9mmol/L

± Proceeded with intubation

± Suctioning noted yellowish secretion from oral and ETT

± Post-intubation: Spo2 95%-97% under FiO2 70%

± Mild SCP ?

± CRT <2s, pulse vol good, HR 140/min

± Temp: 36.7C

± Lung: equal breath sound, clear

±Diagnosis

:congenital pneumonia ± Plan:

admit NICU for ventilation

Keep NBM (TF 60cc/kg/day, D10%: 7cc/hr)

IV C.Penicillin 50000U/ kg, IV gentamicin 5mg/kg

Dxt hourly till stable

Investigation: bld culture and sensitivity, CXR, gastricaspirate(gram stain, culture and sensitivity), CBG



Further management and progression in

NICU

General management:

± Keep baby warm in incubator

± Close vital signs monitoring

± oxygen saturation (keep more than 95%

) ± dextrostix for glucose (> 3.3mmol/L)

± Fluid management

± Daily weight

± Intake and output charting



26/12

± 10am: Start feeding 5cc/3hrly (TF 60cc/kg/day)

± 11.55am: Upon trying to cut down FiO2 to 30%, he

desaturated to 80%, thus, FiO2 was increased to 50% and

saturation regained to 95%

± 2.30am:Noted jaundice up to chest, but active and pink. CRT

<2sec. There was minimal SCR and ICR, S/S 2/10.

crepitations heard over the right lung, but breath sounds equal

bilaterally. Surfactant was given.



Able to reduce FiO2 to 36%. Feeding introduced 5cc 3hrly IVD

1/2NSD10% at 8.9cc/hr (TF 90cc/kg/day)

post surfactant x-ray showed improving RDS



- Serum bilirubin -167, direct- 8

- BUSE: Na 136/ K 2.9/ Urea 1.7/ creat 54

- Intensive phototherapy level for 35 weeks (sick babies) is 135

-thus, he was put under intensive phototherapy and add 1gK

Cl/ pintof fluid



Case Presentation 2



Baby boy of Madam S, 33 years old para2, delivered via

emergency lower segment cesarean section (EMLSCS) at 33

weeks 5days of POA due to severe preeclampsia admitted to

NICU whereby he was noted to have respiratory distress at 5

minutes of life.



Antenatal history of Madam S

33 years old, Malay government servant

Gravida 2 para1

LMP:4/5/2010 EDD: 11/2/2011 POA:33weeks+5days

History of previous scar , GDM on diet control, and preeclampsia

Presented to OGAC at 33weeks +4 days with headache

associated with high BP



Planned and wanted pregnancy

Antenatal booking @ 13 weeks of POA

-dating scan done, confirmed the pregnancy

-B

G:O positive , VDRL,hepB

, HIV: not reactive-BP:120/80mmHg with normal urinalysis (no proteinuria, no

glycosuria)

MGTT done @ 20 weeks due to obesity (BMI: 26)

-preprandial :4.6mmol/L, 2 hours postprandial: 9.8 diagnosed

with GDM

BSP done @24 weeks -4.1/5.0/6.0/5.9, GDM on diet control



Antenatal ultrasound scan:

14 weeks Parameters correspond to date (13-14 weeks)

21 weeks Detailed scan for GDM, parameters correspond todate, no structural anomaly detected

26 weeks Breech presentation, parameters correspond to

date(26-27weeks), EFW:948g, liquor adequate

29weeks Cephalic presentation, parameters correspond to date

(29-31weeks), EFW: 1.5kg, liquor adequate



BP @ 32 weeks: 140/90mmHg

Since then EOD BP: 120-140/80-90

Asymptomatic until presented to OGAC with headache @ 33

weeks +4days of POA, protenuria

IV magnesium sulphate and IV labetolol given

IM dexamethasone given once 5 hours prior to delivery



Past obstetrics and gynecological history:

± Baby boy was born at full term via EMLSCS due to poor

progress at 2008 in UKMMC with the birth weight of 2.75kg.

± No history of hypertension or diabetes during previous

pregnancy

± Achieve menarche at 14yrs old

± Menstrual cycle:30 days, regular , no dysmenorrhea or

menorrhagia

± Not taking oral contraceptive pill



No family history of hypertension in pregnancy or pre-eclampsia.

Her mother is hypertensive, however no diabetes mellitus

No significant past medical

No known allergy to any drug or food

Social history:

± married for 3 years

± Worked as government servant (secretary)

± Husband worked as plan drawer

± No smoking, not consume alcohol



Code pink standby at OT for

prematurity

She delivered a baby boy at 1904hours, 29/12/2010. Premature

at 33/52 + 5/7

Birth weight was 1.69kg (low birth weight)

Apgar score:9 in 1min, 10 in 5min

Clear liquor noted, placenta:350gm, EBL:200cc, pH:7.295

He was cleaned and wrapped and transferred immediately to

radiant warmer



He cried at birth, APGAR: 9/10

Active, pink, not cyanosed, not pale,

HR: 134/min, SpO2: 95%, Temperature: 36.4

He was noted to have nasal flaring

,subcostal recession

, intercostal recession, Silverman score: 3/10 at 5minutes of life

Neopuff CPAP, FiO2: 21% Peep 5unit H2O started ±Silverman

score: 0-1/10



Newborn Screening Anthropometry Birth weight was 1.69kg (low birth weight),head circumference: 29cm,

length: 42cm ±between 10th and 50th percentile

Generalappearance

Pink, not jaundice, active on handling, comfortable, good muscle tone

Head No microcephaly (head circumference between 10th and 50th percentile.

Anterior fontanelle normotensive

Neck N AD

Face No facial dysmorphism.

Eyes

:normal red reflex.

Ears

:normal auricles andauricular canal. Nose: nasal septum intact. Mouth: no cleft lip and palate.

No natal teeth, no central cyanosis

Cardiovascular

system

First and second heart sound heard with no murmur. Femoral pulses

palpable.

Respiratory

system

No chest wall deformity. Breath sounds equal bilaterally. No rhonchi and no

crepitation heard.

Gastrointestinal

system

Abdomen soft, not distended. Umbilical stump:2arteries, 1 vein, anus:

patent

Genitalia Male. Testis:descended

Spine N AD (no tuft of hair , no sacral pit

Immature reflexes Moro¶s reflex not done. Sucking:poor

Limbs No peripheral cyanosis. Hands and feet: no dysmorphism. Hips: stable,



Problem list

1. Prematurity at 33weeks +5days (dated scan at 13 weeks of

POA)

2. Respiratory distress secondary to mild respiratory distress

syndrome/ transient tachypnea of newborn (IM Dexamethasone

given once 5hours prior to delivery)

3. Infant of maternal GDM and severe preeclampsia (IV

magnesium sulphate and labetolol given)

4. Poor sucking secondary to prematurity



Investigations

FBC: look for leukocytosis and its differential

CRP

Procalcitonin

Placenta

:swab and culture and sensitivity

, HPE

Gastric culture and sensitivity

Blood culture and sensitivity



General management

Keep the baby in incubator.

Closed vital signs monitoring.

Oxygen saturation monitoring

Dextrostix for glucose monitoring

Intravenous fluid infusion

Ryle¶s tube feeding(poor sucking)

Daily Weight

I/O chart



In the OT

Admit to labour room for CPAP FiO2:21% Peep 5 units H2O,

keep SpO2: 88-93%, MAP >33

Keep in view antibiotics if septic

Ryle¶s tube insertion and decompress 4 hourly (free flow)

Keep in view Ryle¶s tube feeding when more settle

Intravenous drip (60mls/kg/day)

Dextrostix monitoring



Day 1 (29/12/10)

He is comfortable on NCPAP 21%

Silverman scoring: 0-1/10

DXT: 4.1mmol/L

Investigation: CBG

Plan:

± Start Rtle¶s tube feeding 3cc 3 hourly, intravenous fluid(dextrose 10% 3.3ml/hour), total feeding: 60mg/kg/hour

± Trace results, KIV antibiotics if septic

± DXT 4hourly, keep DXT:>3.3mmol/L

± Try to off CPAP and put nasal prong

± If able to maintain SpO2 and stable, can transfer to NICU semi-intensive

± Observe BP



Day 2 (30/12/10) morning round

Comfortable on NCPAP

When try to off , become more distressed, Silverman score:2/10 when try to

off

Clinically active, pink, weight:1.69kg

Observed apnoic episodes while on NCPAP

Tolerating 3cc 3hourly feeding BO once-meconium, urine output: 1.34cc/kg/hour

HR:120/min, SpO2:98% on NCPAP, CRT: <2 s, good pulse volume

Imp: apnea most likely secondary to maternal sedation (IV magnesium

sulphate)

IX results: Hb:1

8.1, HCT: 53.4, WCC: 6.2, platlet: 134, CRP: 0.03, PCT: 0.31, TSH:3.76, G6PD: normal

Plan: ± Keep NCPAP

± Observe BP and temperature

± Start IV C Penicilin and IV gentamicin

± Start oral caffeine, Apnea and bradycardia charting



Day 2 evening round

Pink, active on handling

Silverman score:0/10 on air , HR: 135/min, SpO2: 98% on air

No apnea and no bradycardia seen

Tolerating feeds 5cc 3hourly via RT P22

Pass urine and BO

I/O over 9hours:16/60(-44)

Urine output: 3.94cc/kg/hour

Plan:

± Increase feeding to 10cc 3 hourly, IVD 1/5 NS Dextrose 10%

3cc/hour

± If tolerate twice, increase feeding to 20cc3 hourly and off IVD



Day 3 (31/12/10)

Pink and active on handling, weight:1.6kg (reduce)

BP:69/32, HR: 130/min, T: 36.8, SpO2: 99% under room air

I/O: 148.1/112(BO thrice) balance: (+36.1)

Urine output: 2.9cc/kg/hour

Plan:

± Off IVD

± Increase feeding 25cc 3hourly (total feeding 120cc/kg/day)

± Trace all cultures

± KIV off antibiotic if culture negative (after completing 48hours)

± Monitor DXT per shift for 1 day, if stableoff



PREMATURITY



Premature infant: <37 weeks of gestations

Low birth weight(LBW): <2500g

Very low birth weight(VLBW): <1500g

Extremely low birth weight(ELBW): <1000g

Small for gestational age: <10th centile of birth weight

for age

Large for gestational age; >90th centile

± Paediatric protocol for Malaysia Hospital, 2nd edit. 2008



Early Ballard Score allows for the estimation of age in the rangeof 26 weeks-44 weeks.

The New Ballard Score introduced in 1991 is an extension toinclude extremely pre-term babies i.e. up to 20-44 weeks

Each criteria are scored from -1 through 5

Neuromuscular and physical maturity



Neuromuscular maturity

Posture

Square window

Arm recoil

Popliteal angle

Scarft sign

Heel to ear

Physical maturity

Skin

Lanugo

Plantar surface

Breast

eye/ear

Genital-male

Genital-female



Assessment Assessment

Neuromuscular Maturity

1. Posture: infant is placed supine and the waits until the infant settles into a

relaxed or preferred posture

2. Square window: examiner straightens the infant's fingers and applies gentlepressure on the dorsum of the hand, close to the fingers

3. Arm recoil: take infant's hand and then briefly sets the elbow in flexion, then

momentarily extends the arm before releasing the hand. The angle of recoil to

which the forearm springs back into flexion is noted



4. Popliteal Angle: thigh is placed gently on the infant's

abdomen with the knee fully flexed and wait for legs to

relaxed

5. Scarf sign: The point on the chest to which the elbow moves

easily prior to significant resistance is noted

6. Heel to ear : flexed lower extremity is brought to rest on the

mattress alongside the infant's trunk.



Assessment (con¶t) Assessment (con¶t)

Physical Maturity

1. Skin: general inspection

2. Lanugo: inspect the upper and lower areas of the infant's

back.

3. Plantar surface: measure distance from tip of great toe to

back of heel and observe for creases



4.Breast: note the size of the areola and the presence or absence of stippling and then palpate the breast tissue

5.Eye/Ear : examine eye lids for fusion and examine pinna of ear for recoil

6.Genitals:

Male ± document the normal side if cryptorchidism suspectedFemale ± abduct hip 45 degree and then assess clitoris, labiamajora and labia minora



Neuromuscular MaturityNeuromuscular Maturity



Neuromuscular maturity: Neuromuscular maturity:

1. Posture1. Posture



2. Square window2. Square window



3. Arm recoil3. Arm recoil



4. Popliteal angle4. Popliteal angle



5. Scarf sign5. Scarf sign



6. Heel to ear 6. Heel to ear



Physical MaturityPhysical Maturity



Physical maturity:Physical maturity:

1. skin1. skin



2. lanugo2. lanugo



3. Plantar surface3. Plantar surface

4 b t4 b t



4. breast4. breast

5 E /5 E /



5. Eye/ear 5. Eye/ear

6 G it l6 G it l ll



6. Genital6. Genital--malemale

GG ff



6. Genital6. Genital--femalefemale



Possible scores then range

from -10 to 50

Possible week range from 20

to 44



DubowitzDubowitz

ScoreScore



Consist of 10 neurological

assessment

11 physical assessment



Differences between Dubowitz and Ballard



Differences between Dubowitz and BallardDubowitz Modified Ballard

More time-consuming ( Sunjoh F et al,

2004)

More easier and faster to score

Cause more stress to the infant cause less stress to the already stressed

preterm infants

More component:

neurological signs = 10

external signs = 11

Less component:

neurological signs = 6

external signs = 6

Scores of individual items vary from 0 to

max 4

-Minimum score = 0

-Maximum score = 72

Scores of individual items vary from -1 to

max 5

-Minimum score = -10

-Maximum score = 50

Estimated gestational age:

= (0.2642 X (total score)) + 24.595

Estimated gestational age:

total score corresponds to its respective

gestational age, eg -10 score = 20 weeks

Not specified Can determine gestational age from 20 to

44 weeks

recommended in research studies suitable in routine clinical practice

Dubowitz Modified Ballard



Dubowitz Modified Ballard

Research showed:

1.Dubowitz score is more valid and

reliable than the Ballard, although

among small-for-gestational-age infants, the Dubowitz score has been shown to

overestimate gestational age (Sunjoh F

et al. 2004)

2.Dubowitz scoring system significantly

overestimated gestational age

compared with the standard gestational

age in preterm infants, especially thoseless than 34 weeks (Shukla H et al.

1987, Robillard PY et al. 1992)

3.Despite moderate agreement between

Dubowitz score and BPD in the

assessment of gestational age,

agreement in the classification of low-birth-weight infants as SGA and as

premature births was good. (Vik T et al.

1997)

Research showed:

1.New Ballard score is more accurate

and easier to administer than the

Dubowitz (SunjohF

et al. 2004)2.The NBS is a valid and accurate

gestational assessment tool for

extremely premature infants (Ballard

JL et al. 1991)

3.Require less clinical skill and accurate

in low-resource setting (Feresu S A,

2003)



Other methodsOther methods

Last Menstrual Period

Eregie Score Method

Farr Score Method

Parkin Score Method

Cappuro Score Method

Finnstrom Score Method

Ultrasound



RESPIRATORY DISTRESS

SYNDROME

Risk factors:

-preterm

- Maternal diabetes

- Perinatal asphyxia

- Elective caesaerian section

Clinical features : (present shortly after birth)

- Tachypnoea

- Chest wall recession (sternal,subcostal,intercostal)

- nasal flaring

- grunting

- cyanosis 1.Tom Lissauer , Graham Clayden. Illustrated textbook of Paediatrics 3rd edition.2.Ricardo J Rodriguez. Management of respiratory distresssyndrome. Respiratory care. March 2003. Vol 48.



-Bilateral homogenous ground-glass

appearance of lungs field

- air-bronchogram

-indistinct heart border (in severe case)

- loss of vessel outline

RADIOLOGIC AL FEATURESres:



Management for

RDS



Antenatal steroids for prevention

Given to patients who are at risk of premature delivery at 24 to 34

weeks of gestation.

Risk of preterm labour

Preterm premature rupture of membrane

Antepartum hemorrhage

Any condition requiring elective preterm delivery



Steroid and Dosage

IM Dexamethasone 12mg BD 12 hours apart.

OR

IM Betamethasone 12mg 24 hours apart.

Yun Hsuen Lim.2006.Handbook of Labour

Room Practice,Department of O&G UKM



Advantage of betamethasone

Less risk of periventricular leukomalacia

Better fetal lung affinity

Better alveolar resorption



Surfactant replacement

Expensive Indication :

In premature infant <32 weeks or birth weight <1.5kg

More mature infant/larger if RDS is severe.

2 main classes of surfactant : ± Natural

± Synthetic

Type of surfactant and dosage :

± Survanta (natural) ± Dose : 4ml/kg per dose.1st dose given in first 2 hours after

birth.

± Repeat 6 hours later if needed.

Paediatric Protocols for Malaysian Hospital,2nd Edition



Administration : Via endotracheal tube

2 therapeutic approaches :

-Prophylactic (given within minutes after birth)

-Rescue (established RDS requiring supplemental oxygen and

mechanical ventilation)

Advantage of prophylactic approach:

± Reduce incidence of BPD ± Reduce the need for mechanical ventilation or subsequent

supplemental oxygen

Management of Respiratory Distress Syndrome : An Update

Ricardo J Rodriguez MD, Respiratory Care Journal,March 2003 Vol

48 No 3



Rescue approach :

Advantage :

± Reduce cost and morbidity a/w unnecessary surfactant

therapy.

Disadvantage :

± Delay of replacement may decrease its efficacy and allow

progression of lung injury

Management of Respiratory Distress Syndrome : An Update

Ricardo J Rodriguez MD, Respiratory Care Journal,March 2003 Vol 48 No 3



Ventilatory Support

Goal : To maintain adequate oxygenation and ventilation,while

minimizing ventilator-induced lung injury.

1.Continuous Positive Airway Pressure (CPAP)

-positive pressure applied to the airways of a spontaneously

breathing baby throughout the respiratory cycle

-re-expands collapsed alveoli,splints airway,reduce work of

breathing and improves the pattern and regularity of respiration.

Immediate respiratory management of the preterm infant

Sunil K. Sinha, Samir Gupta, Steven M. Donn, Seminars in Fetal & Neonatal

Medicine (2008) 13, 24-29



Mechanical Ventilator

Controlled Mode Ventilator (CMV)/Intermittent Positive Airway

Pressure (IPPV)

± Patient is intubated.

± Used in severe RDS with lung disease to

correct respiratory acidosis and hypoxemia.

Disadvantage :

1.Pulmonary barotrauma ±esp pneumothorax.

2.Infection ± pulmonary3.Complications due to prolonged intubation-

airway edema,tracheal stenosis,laryngeal ulcer.

Mechanical ventilation of lungs, MedchromeOnline Medical and Health

Magazine



Other types :

± Synchronized Intermittent Mandatory Ventilation (SIMV)

± Positive End Expiratory Pressure (PEEP)

± Inverse Ratio Ventilation (IRV)

± Biphasic Positive Airway Pressure (BiPAP)



THANK YOU

management for rds

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