Case Report

Kepada Yth.

Perinatology Unit
RESPIRATORY DISTRESS EC TRANSIENT TACHYPNEA OF
NEWBORN
Presenter

: Muhammad Faiz Bin Hashim (100100402)

Day/Date

: Friday/ June 6th 2014

Supervisor in charge : dr. Bugis Mardina Lubis, Sp.A(K)

Supervisor

: dr. Bugis Mardina Lubis, Sp.A(K)

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

hypoventilation effect from drug intoxication or infection. A thorough evaluation

must be done based on history taking, complete physical examination,
laboratorium and radiologic finding that lead to diagnosis. Serial evaluation on
consciousness, respiratory sign, blood gas analysis and therapy responsiveness
must be taken for further intervention.
a) History taking
History taking on family , maternal, prenatal and interpartum history must be
taken, and other important point that will listed below:-

Prematurity,

respiratory

distress

syndrome,

meconium

aspiration

syndrome, infection: pneumonia, pulmonary dysplasia, nasal congestion,

CNS depression and bleeding, phrenic nerve paralysis, bradycardia and
tachycardia on neonates, neonatal depression, trauma during inverse
partus.

CNS depression: hypertonia, flaccidity, atonia, trauma, myasthenia

Congenital abnormalities: single umbilical artery, cardiopulmonary

anomaly, erb paralysis, choanal atresia, obstructive nasal congestion,
increased diameter of anterior posterior lung, lung hypoplasia,
tracheoesophageal fistula.

Maternal diabetes, antepartum hemorrhage, prolonged partus, premature

rupture of membrane, oligohydramnion.

b) Physical examination
On physical examination, we will find clinical sign of respiratory distress such
as:

Grunting

Cyanosis

Retraction

Sign of airway obstruction (choanal obstruction)

Amniotic fluid mixed with meconium or yellowish green discolouration of

umbilicus.

Scaphoid abdomen

c) Laboratorium findings
a) Blood Gas Analysis

o Sign of acute respiratory failure: PaCO > 50 mmHg, PaO <

60 mmHg, Oxygen saturation < 90%.
o Blood samples is taken from umbilical artery or arterial puction
o Indicator of metabolic acidosis, respiratory acidosis and
hypoxic condition.
o Respiratory acidosis occurs because of alveolar atelectasis
and/or lower respiratory tract overdistention.
o Metabolic acidosis usually because of primary lactic acidosis,
result from poor tissue perfusion and anaerobic metabolism.
o Hypoxia occurs when there are left to right shunt between
pulmonary circulation, PDA and/or persistent foramen ovale.
o Pulse Oxymeter is used as non invasive method for evaluate
oxygen saturation.
b) Electrolytes
o Increased

in

bicarbonates

ion

result

from

metabolic

compensation of chronic hypercapnia.

o Blood glucose level to eliminates hypoglycaemia
o Hypokalemia, hypocalcemia, hypophosphatemia can cause
disturbance of muscle contraction
c) Radiologic findings
o Chest x-ray: diffuse reticulo granular bilateral, or air
brochcogram and unexpanded lung.
o Cardiac silhouette: normal or enlarge
o Cardiomegaly: prenatal asphyxsia, maternal diabetes, PDA,
other congenital heart disease.
o Thorax transillumination test: detect abnormal air deposition
such as in pneumothorax.
o Detect pneumonia, pneumothorax, bilateral hyperinflation,
pleural effusion, and endotracheal tube malposition.
Treatment
Treatment for neonatal respiratory distress can be both generalized and
disease-specific. Physicians should be aware of current neonatal resuscitation
6

protocols. Oxygenation can be enhanced with blow-by oxygen, nasal cannula, or

mechanical ventilation in severe cases. Surfactant administration may be required.
Antibiotics are often administered if bacterial infection is suspected clinically or
because of leukocytosis, neutropenia, or hypoxemia. Ampicillin and gentamicin
are often used together based on their effectiveness and synergy. Extracorporeal
membrane oxygenation, similar to an artificial external lung, is used as a last
resort in critical circumstances. Oral feedings are often withheld if the respiratory
rate exceeds 80 breaths per minute.
If pneumothorax occurs, needle decompression or chest tube drainage may
be required. Small pneumothoraces can be treated in term infants without invasive
management through nitrogen washout. Administration of 100% oxygen can
accelerate the resolution of the pneumothorax as readily absorbed oxygen replaces
nitrogen in the extrapulmonary space. This technique can reduce pneumothorax
duration from two days to eight hours.
Because evidence in the specific treatment of neonatal respiratory distress
continues to evolve, family physicians should work conjointly with neonatal
intensivists. If services required for the neonate are unavailable at the family
physician's facility, care should be transferred to a higher acuity hospital.
Transient Tachypnoe of Newborn (TTN)
Definition
TTN is a parenchymal lung disorder characterized by pulmonary edema
that results from delayed resorption and clearance of fetal alveolar fluid in term
infants. The excess fluid in the lungs in TTN results in decreased pulmonary
compliance and increased airway resistance. The mechanism causing changes in
pulmonary function are primarily associated with the extrinsic compression of
small airways by fluid in the extra-alveolar interstitium. Tachypnea develops to
compensate for the increased work of breathing associated with reduced
compliance and increased airway resistance.
Risk Factors

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

cardiomegaly, increased lung volume, and increased anteroposterior chest

diameter. A study conducted of morethan 2800 babies reported in 2003
found a subset of infants whose clinical appearance indicated TTN but
whose chest film was clear. This suggest that TTN can occurs despite of
normal chest findings.
Management

Management of TTN is supportive. Although infants exhibiting mild

tachypnea, can usually be observed for a few hours in a newborn nursery.
Significant tachypnea (> 60-80/min) prevents oral feeding and necessitates to
higher level of care for initiation of intravenous fliud and monitoring. In selected,
situation, an orogastric or nasogastric tube can be placed for assistance with
feeding, but only after determining that the infants is unlikely to require
ventilatory support. Because of concern of gastroesophageal reflux and aspiration,
infants with respiratory rate greater than 90 to 100 breath per minutes should not
received oral or gastric feeding. However placement of an orogastric or
nasogastric tube for stomach decompression may be helpful to maximise lung
expansion. Supplemental oxygen mey be needed, and nasal continuos positive air
pressure may be required for infant exhibiting persistent and significant work of
breathing.Althuogh some has proposed that furosemide may be useful in the
treatment of TTN, studies has not comfirmed that it has any roles.

10

CASE REPORT
Name

: by TT

Age

: 1 day

Sex

: Male

Date of Admission

: May, 9th 2014

Chief Complaint

: dyspnea

History

: this newborn named TT was delivered by cesarean section

on indication previous SC one times. Gestational age 36-37
weeks + PK + AH + inpartu + suspect congenital heart
disease. On 9th May 2014, 14.50WIB, the newborn
delivered, not crying, body and extremites was cyanosis,
Then the newborn was placed under infant warmer and
tactile stimulus and dried up was done. Then the baby
crying, the body was reddish and extremites was bluish
color. Oxygen was given by using nasal cannule, the
extremites then become reddish. The baby were observed
for 15 minutes. Then the umbilicard cord was amputated,
and wrapped with sterile gauze and was placed in incubator.

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

:-

History of Growth and Development

History of previous illness

:-

History of previous medications

:-

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 :
-

Large crown open flattened. Head circumference: 34 cm.

Eye: Isochoric pupil, inferior palpebra conjunctiva pale (-/-), conjunctivitis (-),

icteric sclera (-/-), light reflex (+/+).

Face: within normal limit
Ear: within normal limit
Nose: nasal canule (+), Naso gastric tube (+)
Mouth: within normal limit

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

Laboratory Findings (May 10th 2014):

Parameters
Complete Blood Count
Hemoglobin
Hematocrite
Erithrocyte
Leucocyte
Platelet
MCV
MCH
MCHC
RDW
Diftel
Parameters
Blood Gas Analysis
pH
pCO
pO
Bicarbonate(HCO)
Total CO
Base Excess (BE)
O saturation
Carbohydrate
Blood Glucose (ad random)
Electrolytes
Calcium
sodium
Pottasium
Phosphate
Chloride
Magnesium
Autoimmune
CRP qualitative
Other test
Procalcitonin

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 /

13,4 19,8 gr%

51 65%
5,33 5,47 x 106 /mm3
6.0 17.5x 103 /mm3
217.000 497.000 /mm3
104 116 fl
35 39 pg
32 34 gr%
14,9 18,7 %
1-6/0-1/37-80/20-40/2-8

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:
-

Respiratory Distress ec Transient Tachypea of Newborn (TTN)

Respiratory distress ec Hyaline Membrane Disease (HMD)

Low Birth weight

Working Diagnosis:

Respiratory Distress ec Transient Tachypnea of Newborn (TTN) + Low

birth Weight + suspect Sepsis

Management:
-

CPAP with FiO 30% PEEP 6 saturation target 88 92%

Total fluid requirement 80mL / kg / day = 192 mL/day
o Parenteral 80 mL/ kg/ day = 192 mL/ day
o IVFD D10% +Ca gluconas 10 mL = 8 mL/hour
o Enteral : Trophic feeding 10 mL/kg/hour = 24mL/day
o Dipt AH IPAH 2mL/2 hour/ orogastric tube
Inj Ceftazidine 120mg/12 hour/IV
Inj gentamisin 12 mg/36 hour/IV
Inj. Vit K 1mg/IM
Replacement of wet diapers

Diagnostic Planning:
-

Septic workup

Complete blood count

Glucose ad random

Electrolyte (Na, K, Cl)

Blood gas analysis

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

Large crown opened flat.

Eye: Isochoric pupil, inferior palpebra conjunctiva pale
(+), \ icteric sclera (-/-), light reflex (+/+).
Face: within normal limit
Ear: within normal limit
Nose: CPAP FiO 25% flow & L/I PEEP= 6, Sat 88-90%

Neck
Thorax

Mouth: inserted with orogastric tube

Within normal limit
Symmetrical fusiformis, chest retraction (+) epigastrial, HR:

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

Na./ K/ Cl/ Ca/ Mg/ P : 140/4,1/111/6,8/2,63/ 6,2

Ca: 0,889, Glucose : 56, CRP : (+), Procalcitonin: 38,44
Workup:
a) Hypoglycemia correction : 2mL/kg/ IV = 5mL (D10% bolus)
b) Hypocalcemia correction : 2mL/kg/IV = 5mL (Ca Gluconas in 5mL
D5%) , complete in 6 hours = 1,5mL/hour

May 11th 2014

S dyspnea(+) minimal, fever(-), suckling effort weak, movement weak
O Sens: Alert, Temp: 36,8oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-).
Dyspnoe (+) Body weight: 2,4 kg, Body length: 42 cm.
Head

Large crown open flatten. Head circumference:

Eye: Isochoric pupil, inferior palpebra conjunctiva pale
(-/-),icteric sclera (-/-), light reflex (+/+).
Face: within normal limit
Ear: within normal limit
Nose: FiO 25% flow & L/I PEEP= 6, Sat 88-90%

Neck
Thorax

Mouth: orogastic tube inserted

Within normal limit
Symmetrical fusiformis, chest retraction (+) epigastrial, HR:

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:
-

CPAP with FiO 30%, PEEP 5, Saturation O < 95%

Total fluid requirement 100mL/kg/day = 216mL/day
o IVFD D10% + Ca gluconas 10cc = 18gtt/I micro
o Enteral; trophic feeding 30mL/kg/days = 72mL/days
o Diet ASI/PASI 6mL/2 jam/ OGT
- Inj. Ceftazidine 120mg/12 hour/IV (H2)
- Inj Gentamisin 12mg/36 hour/ IV (H2)

16

May 12th 2014

S Dyspnea(+), fever(-), suckling effort weak, movement weak
O Sens: Alert, Temp: 37,0oC. Anemic (-). Icteric (-). Edema (-). Cyanosis (-).
Dyspnoe (+)
Head

Large crown open flatten. Eye: Isochoric pupil, inferior

palpebra conjunctiva pale (-/-), icteric sclera (-/-), light
reflex (+/+).
Face: within normal limit
Ear: within normal limit

Neck
Thorax

Mouth: inserted with OGT,

Within normal limit
Symmetrical fusiformis, chest retraction (+) epigastrial, HR:

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

May 13th 2014

S Dyspnea(+), fever(-), suckling effort weak, movement weak, jaundice(+)
O Sens: Alert, Temp: 36,8oC. Anemic (-). Icteric (+). Edema (-). Cyanosis (-).
Head

Large crown opened flat.Eye: Isochoric pupil, inferior

palpebra conjunctiva pale (-/-),icteric sclera (-/-), light reflex
(+/+).
Face: within normal limit
Ear: within normal limit

17

Nose: within normal limit, nasal cannule low flow

0,5L/min, O saturation 90-93%.
Neck
Thorax

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:
-

Radian infant warmer target skin temperature 36,5 37,5C.

O nasal cannule low flow 0,5L/min
Toral fluid requirement 130mL/kg/day = 312mL/day
o Parenteral 80mL/kg/day = 192mL/day
o IVFD D5%, NaCl 0,225%(430mL) + D10%(70mL) + KCl 10mEq +

Ca Gluconas 10mL = 18gtt/I micro

o Enteral 50mL/kg/day = 120mL/day
o Diet PASI/ASI 10mL/2hour/OGT
- Inj Ceftazidine 120mg/12hour/IV (D4)
- Inj. Gentamisin 12mg/36hour/IV (D4)
- Nystatin Drop 3 x 0,5cc
Laboratorium finding
Billirubin total : 10,74 Bilirubin direct: 0,36 Glucose: 85,5
Na/K/Cl/Ca/Mg/P : 141/4/109/8,4/3,01/5,8
pH/pCO/pO/HCO/TCO/BE/SO/Ca : 7,316/33,6/129,1/16,7/17,8/8,5/98,3/1,1
May 14th 2014
S Dyspnea(+) minimal, icterus(+), suckling effort weak
O Sens: Alert, Temp: 37,5oC. Anemic (-). Icteric (+). Edema (-). Cyanosis (-).
Dyspnoe (-) Body weight: 2,2 kg,
Head

Large crown open flattend.

Eye: Isochoric pupil diameter 3mm, inferior palpebra
conjunctiva pale (-/-), light reflex (+/+).
Face: within normal limit

18

Ear/Nose: within normal limit,

Neck
Thorax

Mouth: within normal limit

Within normal limit
Symmetrical fusiformis, chest retraction (+) epigastrial,
vesicular, HR: 148 bpm, regular, murmur (-). RR: 58x/i,

Abdomen
Extremitie

A
P

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 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

May 15th 2014

S Dyspnea(+) minimal, icterus (+), suckling effort weak, active movement
O Sens: Alert, Temp: 37,3oC. Anemic (-). Icteric (+). Edema (-). Cyanosis (-).
Head

Large crown open flat.

Eye: Isochoric pupil, inferior palpebra conjunctiva pale (-/-),
light reflex (+/+).
Face: within normal limit
Ear: within normal limit

Neck
Thorax

Nose: CPAP FiO 21%,PEEP 5, O saturation 90-92%

Within normal limit
Symmetrical fusiformis, chest retraction (+) epigastrial, HR:

Abdomen
Extremitie

148 bpm, regular, murmur (-). RR: 58x/i, reguler,

Rapid turgor, normal peristaltic, liver and spleen unpalpable
Pulse 148 bpm, regular, adequate pressure and volume,

warm, CRT < 3.

19

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

May 16th 2014

S Dyspnea(+) minimal, icterus (+), suckling effort weak, active movement
O Sens: Alert, Temp: 37,0oC. Anemic (-). Icteric (+). Edema (-). Cyanosis (-).
Head

Large crown open flatten.

Eye: Isochoric pupil, inferior palpebra conjunctiva pale (-/-),
light reflex (+/+).
Face: within normal limit
Ear: within normal limit

A
P

Neck
Thorax

Nose: Nasal cannule inserted

Within normal limit
Symmetrical fusiformis, chest retraction (+) epigastrial, HR:

Abdomen
Extremitie

146 bpm, regular, murmur (-). RR: 56x/i, regular, vesicular.

Rapid turgor, normal peristaltic, liver and spleen unpalpable.
Pulse 146 bpm, regular, adequate pressure and volume,

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

o Enteral 100mL/kg/day = 240mL/day

o Diet PASI/ASI 20mL/2hour/OGT
- Inj. Ceftazidine 120mg/12hour/IV (D7)
- Inj. Gentamisin 12mg/36hour/IV (D7)
Nystatin drop 3 x 0,5mL
Further plan
-

Blood culture, CBC, BGA, Electrolytes,Bilirubin, glucose, CRP, PC

May 17th 2014

S Dyspnea(+) minimal,icterus(+), suckling effort weak
O Sens: Alert, Temp: 36,9oC. Anemic (-).Edema (-). Cyanosis (-).Body weight:
2,11kg..
Head

Large crown open flatten.

Eye: Isochoric pupil, inferior palpebra conjunctiva pale
(-/-),light reflex (+/+).
Face: icteric(+)
Ear: within normal limit
Nose: O nasal cannule inserted

A
P

Neck
Thorax

Mouth: orogastric tube inserted.

Within normal limit
Symmetrical fusiformis, chest retraction (-), icterus(+) HR:

Abdomen

142 bpm, regular, murmur (-). RR: 52x/i, regular.

Icterus(+), Rapid turgor, normal peristaltic, liver and spleen

Extremitie

unpalpable, umbilical dried.

Pulse 142 bpm, regular, adequate pressure and volume,

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

- Nystatin drop 3x 0,5mL

treatment planning:
- Light therapy for 24 hours
May 18th 2014
S Dyspnea(+) minimal, icterus(+), suckling effort weak
O Sens: Alert, Temp: 37,0oC. Anemic (-)Edema (-). Cyanosis (-).Body weight:
2,11 kg.
Head

Large crown open flat.

Eye: Isochoric pupil, inferior palpebra conjunctiva pale
(-/-),light reflex (+/+).
Face: within normal limit
Ear: within normal limit
Nose: O nasal canule inserted

A
P

Neck
Thorax

Mouth: orogastric tube inplaced

Within normal limit
Symmetrical fusiformis, chest retraction (-), HR: 140 bpm,

Abdomen

regular, murmur (-). RR: 50x/i, regular.

Rapid turgor, normal peristaltic, liver and spleen unpalpable,

Extremitie

icterus (+).
Pulse 140 bpm, regular, adequate pressure and volume,

s
Genital

warm, CRT < 3, icterus (+).

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 (D9)
- Inj. Gentamisin 12mg/36hour/IV (D9)
- Nystatin drop 3x 0,5mL

22

May 19th 2014

S Dyspnea(+) minimal, icterus(+), suckling effort weak
O Sens: Alert, Temp: 36,9oC. Anemic (-)Edema (-). Cyanosis (-).Body weight:
2,21 kg.
Head

Large crown open flat.

Eye: Isochoric pupil, inferior palpebra conjunctiva pale
(-/-),light reflex (+/+).
Face: Icterus (+)
Ear: within normal limit
Nose: O nasal canule inserted

A
P

Neck
Thorax

Mouth: orogastric tube inplaced

Within normal limit
Symmetrical fusiformis, chest retraction (-), HR: 142 bpm,

Abdomen
Extremitie

regular, murmur (-). RR: 38x/i, regular.icterus (+)

Rapid turgor, normal peristaltic, liver and spleen unpalpable
Pulse 142 bpm, regular, adequate pressure and volume,

s
warm, CRT < 3.
Genital
Male, within normal limit.
- Respiratory distress ec Transient tachypnea of newborn +
hiperbilirubinemia indirect+ unproven sepsis + low birth weight
Management:
-

Placement in incubator 31 33,2C, 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 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

May 20th 2014

S Dyspnea(+) minimal, icterus(+), suckling effort weak
O Sens: Alert, Temp: 36,8oC. Anemic (-)Edema (-). Cyanosis (-).Body weight:
2,24 kg.
Head

Large crown open flat.

Eye: Isochoric pupil, inferior palpebra conjunctiva pale
(-/-),light reflex (+/+).
Face: Icterus (+)
Ear: within normal limit
Nose: O nasal canule inserted

A
P

Neck
Thorax

Mouth: orogastric tube inplaced

Within normal limit
Symmetrical fusiformis, chest retraction (-), HR: 144 bpm,

Abdomen
Extremitie

regular, murmur (-). RR: 40x/i, regular.icterus (+)

Rapid turgor, normal peristaltic, liver and spleen unpalpable
Pulse 144 bpm, regular, adequate pressure and volume,

s
warm, CRT < 3.
Genital
Male, within normal limit.
- Respiratory distress ec Transient tachypnea of newborn +
hiperbilirubinemia indirect+ unproven sepsis + low birth weight
Management:
-

Placement in incubator 31 33,2C, 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 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

May 21th 2014

S Dyspnea(+) minimal, icterus(-), suckling effort weak
O Sens: Alert, Temp: 36,8oC. Anemic (-)Edema (-). Cyanosis (-).Body weight:
2,28 kg.
Head

Large crown open flat.

24

Eye: Isochoric pupil, inferior palpebra conjunctiva pale

(-/-),light reflex (+/+).
Face: Icterus (+)
Ear: within normal limit
Nose: O nasal canule inserted

A
P

Neck
Thorax

Mouth: orogastric tube inplaced

Within normal limit
Symmetrical fusiformis, chest retraction (-), HR: 146 bpm,

Abdomen
Extremitie

regular, murmur (-). RR: 40x/i, regular.icterus (-)

Rapid turgor, normal peristaltic, liver and spleen unpalpable
Pulse 146 bpm, regular, adequate pressure and volume,

s
warm, CRT < 3.
Genital
Male, within normal limit.
- Respiratory distress ec Transient tachypnea of newborn +
hiperbilirubinemia indirect+ unproven sepsis + low birth weight
Management:
-

Placement in incubator 31 33,2C, 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 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

DISCUSSION AND SUMMARY

Discussion
By TT, 1 days, male, was admitted to perinatology division RSUP HAM at
May 9th 2014 diagnosed with respiratory distress ec Transient tachypnea of
newborn (TTN) + hiperbilirubinemia indirect + unproven sepsis + low birth
weight. The diagnosis of respiratory distress was made based on clinical findings
found in the patient such as tachypnea, grunting,chest retraction and cyanosis
which is the symptom of respiratory distress. This neonates also delivered by
cesarean section with normal gestational age which increases the risk of TTN.
Diagnostic of TTN commonly according to symptoms which
can be seen. This diagnosis is also supported with laboratorium
test and chest x-ray. The common symptom of TTN is a
respiratory distress. Then a laboratorium finding of TTN is usually
mild

respiratory

acidosis

due

to

mild

hypoxemia

and

hypercapnia.. Tachypnea can be assessed from counting breath

frequency along one minute when the infant at calm condition.
Dyspnoe can be assessed by looking chest retraction at the lower

27

chest region when the infant inhaled (epigastrium retraction).

According to the Downes Score, we can classified respiratory
distress based on severity of distress. On chest x-ray, we will find
prominent central marking suggestive of vascular engorgement, moderate
cardiomegaly, increased lung volume, and increased anteroposterior chest
diameter.In this patient, the laboratorium shows metabolic acidosis,
electrolyte imbalance and increased in procalcitonin and CRP.Its
maybe the sign of sepsis. TTN is transient disease that will recover by 72
hour after delivery, but the supportive treatment and the complication treatment
should be done if the symptom is not reduced. This patient was warded in
perinatology ward to support the neonatal ventilation using CPAP . And also this
patient was treated with specific antibiotic to eradicate microorganism that can
cause sepsis. Nutritional support also was given to this patient to increase body
weight.

Summary
This paper reports a case of a 1 days, male patient diagnosed wih with
respiratory

distress

ec

Transient

tachypnea

of

newborn

(TTN)

hiperbilirubinemia indirect + unproven sepsis + low birth weight

+
. A

comprehensive treatment with ventilatory support, antibiotics and electrolyte

correction indeed. Adequate nutrition is absolutely supporting child healing from
respiratory distress, and improving his growth and development progress.

28

REFERENCES

1. Ikaria Inc, Understanding Transient tachypnea of Neonates, 2012

2. Kim S.Y., Neonatal respiratory distress: recent progress in understanding
pathogenesis and treatment outcomes, Korean Journal of Pediatrics, Vol 53,
No 1, 2010.
3. Hermansen C.L., Lorah K.N., Respiratory Distress in the Newborn. American
Family Physician,Vol 76,No 7, 2007
4.

Kicklighter S.D., Transient Tachypnea of Newborn. Vol 6, No2, Maggio,

2006.

5. Kasim M.S., Respiratory distress in neonates. Lecture Book of Neonatology,

Indonesia Pediatrics Association, 2010.
6.

Zaoutis L.B., Chiang V.W., Comprehensive Pediatric Hospital Medicine,

Mosby Inc, 2007

29

30