management for rds
TRANSCRIPT
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 1/85
PREMATURITY
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 2/85
Case presentation 1
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 3/85
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.
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 4/85
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?
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 5/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 6/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 7/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 8/85
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.
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 9/85
In HDU:
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 10/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 11/85
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.
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 12/85
± 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.
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 13/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 14/85
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)
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 15/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 16/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 17/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 18/85
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 19/85
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.
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 20/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 21/85
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 22/85
- 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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 23/85
Case Presentation 2
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 24/85
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.
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 25/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 26/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 27/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 28/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 29/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 30/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 31/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 32/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 33/85
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,
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 34/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 35/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 36/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 37/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 38/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 39/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 40/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 41/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 42/85
PREMATURITY
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 43/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 44/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 45/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 46/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 47/85
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.
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 48/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 49/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 50/85
Neuromuscular MaturityNeuromuscular Maturity
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 51/85
Neuromuscular maturity: Neuromuscular maturity:
1. Posture1. Posture
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 52/85
2. Square window2. Square window
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 53/85
3. Arm recoil3. Arm recoil
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 54/85
4. Popliteal angle4. Popliteal angle
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 55/85
5. Scarf sign5. Scarf sign
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 56/85
6. Heel to ear 6. Heel to ear
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 57/85
Physical MaturityPhysical Maturity
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 58/85
Physical maturity:Physical maturity:
1. skin1. skin
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 59/85
2. lanugo2. lanugo
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 60/85
3. Plantar surface3. Plantar surface
4 b t4 b t
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 61/85
4. breast4. breast
5 E /5 E /
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 62/85
5. Eye/ear 5. Eye/ear
6 G it l6 G it l ll
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 63/85
6. Genital6. Genital--malemale
GG ff
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 64/85
6. Genital6. Genital--femalefemale
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 65/85
Possible scores then range
from -10 to 50
Possible week range from 20
to 44
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 66/85
DubowitzDubowitz
ScoreScore
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 67/85
Consist of 10 neurological
assessment
11 physical assessment
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 68/85
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 69/85
Differences between Dubowitz and Ballard
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 70/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 71/85
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)
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 72/85
Other methodsOther methods
Last Menstrual Period
Eregie Score Method
Farr Score Method
Parkin Score Method
Cappuro Score Method
Finnstrom Score Method
Ultrasound
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 73/85
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.
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 74/85
-Bilateral homogenous ground-glass
appearance of lungs field
- air-bronchogram
-indistinct heart border (in severe case)
- loss of vessel outline
RADIOLOGIC AL FEATURESres:
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 75/85
Management for
RDS
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 76/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 77/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 78/85
Advantage of betamethasone
Less risk of periventricular leukomalacia
Better fetal lung affinity
Better alveolar resorption
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 79/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 80/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 81/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 82/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 83/85
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
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 84/85
Other types :
± Synchronized Intermittent Mandatory Ventilation (SIMV)
± Positive End Expiratory Pressure (PEEP)
± Inverse Ratio Ventilation (IRV)
± Biphasic Positive Airway Pressure (BiPAP)
5/12/2018 Management for RDS - slidepdf.com
http://slidepdf.com/reader/full/management-for-rds 85/85
THANK YOU